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xPersonal statementsMike ThomsonWhy Pediatric Endoscopy?Please forgive this indulgence, but as you maydivine from this, I am clearly a little toofocussed, and some may say ‘sad and obsessed’,with this area of medicine!Like most things in life, and particularly inthe serendipitous, chaotic and mal-designedworld of medical careers, I ‘fell’ in to endoscopyin children. Which does sound a little ‘messy’!I am very grateful to George my co-Editorand massive contributor for the opportunity tojoin him in this venture - we did it together forthe Second Edition 10 years ago, and this version has massively surpassed that one. MarvinAment should not be forgotten as an integralpart of the first and second Editions - a realprogenitor of paediatric endoscopy. We hopethat this Third Edition has kept pace with thisfast-changing field.I was first exposed to endoscopy in childrenin 1986 in a large teaching hospital in theNorth of England where it was ‘hold themdown, minimally sedate, and get on with it.’Things have changed a bit since then!However, to be fair, at that point, I did not ‘getthe bug’ for pediatric endoscopy. It was reallystill in its infancy, having been championed inthe late 1970s and early 1980s by such giants ofthe field as Sami Cadranel (so sadly, recentlyleft us), Marvin Ament and Jean-FrancoisMougenot. Sami, Jean-Francois and I were(much) later get to know each other andbecome friends. They and many others set thescene for the undertaking of children’sendoscopy by children’s specialists in GI – acause I have always believed in and tried toimplement. Who wants an adult surgeondoing a quick sigmoidoscopy on your childwith suspected Crohn’s and taking no biopsies? Never mind not getting to the ileum!Hobby horse time – I always call the lower GIprocedure an ileo-colonoscopy not simply acolonoscopy. Why, for instance, would you behappy with having a bronchoscopy where thebronchoscopist only examined the trachea andmain left and right bronchi without going further? Or even just the left lung and not theright?!My first inspirational moment came when Itook up the position of GI/Hepatology Fellowin the Royal Brisbane Children’s Hospital inAustralia in 1989 - a perfect equation of workhard/play hard. My mentor Prof Ross Shepherdwas, and is, one of the most astute clinicians Ihave had the good fortune to learn from - andluckily he was a great teacher of endoscopy aswell. Prof Geoff Cleghorn and Dr Mark Patrickdeserve mention here as well and impartedknowledge and skill tips that I have not forgotten. Australia at this point were streets ahead ofEurope in this area and in the 5 years I wasthere I had an accelerated endoscopy training,which, like many things in medicine, was downto good luck rather than good management.Also undertook my MD Doctorate on CF here.Quick story - on our research staff we had avet called Ristan Greer and I had a patient whohad recurrent H pylori type bug called thenGastrospirillum hominis (now Helicobacterheilmanii) only usually previously seen in catsand dogs – we agreed to scope the cats anddogs at their farm with Ristan anesthetisingthem and using an old scope that was to bethrown out we identified the micro-organismin the cats, gave eradication to the girl and thecats simultaneously, and she was ‘cured’. Cue apaper in The Lancet.Watersheds occur in life, and I chose, forfamily reasons, to return to the UK in 1994.Birmingham and Dame Professor DeirdreKelly CBE and her world-leading liver unitawaited. Gulp. Without doubt one of the mostinspirational women and doctors in the UK, tothis day. When I first arrived, I met Sue theamazing PA to Deirdre, and after she hadshown me my office – in a Portacabin! – I askedher ‘Are you doing that accent for a joke?’ Ittook a while for me to get back in to her goodbooks! It was easy transferring skills but not soeasy adapting back to a West Midlands climate.I loved my time there but the only things thatthe two cities have in common is the letter ‘B’.

Personal statementsNo beach or surf in Brummie. Made somegreat life-long friends there though. I clearlyremember getting a phone call, possibly‘tongue in cheek’, from the head histopathologist in Birmingham Children’s Hospital twoweeks after I had started. I had performed ascope on a post-transplant girl and sent thebiopsies off. He said I had mislabelled the samples because I had put ‘terminal ileum’ on one,and they hadn’t seen that label for years, sowas I sure! And so to another mentor, theextraordinary Deirdre Kelly, from whom Ilearnt many things - but not much endoscopy.But another good friend which the journey ofmedicine has allowed me to make. She wasinstrumental in my application to then becomea Consultant with the incomparable Prof JohnWalker-Smith, one of the fathers of our discipline, at the Royal Free Hospital in London.Got lost, nearly missed the interview, swore Iwould never work and live in London - got thejob and moved to London.The next ten years were eye-opening. The‘dream-team’ of JAWS (which acronym Iknow he dislikes), Simon Murch, Alan Phillips,me and latterly Rob Heuschkel were as closeto a medical family as is possible. We shouldremember here our friend Dave Casson whosadly passed away from gastric cancer.Importantly I was privileged to learn at John’sfeet but almost, if not more, significant for me,I was able to hone my apprentice-type ileocolonoscopy skills with the greatest of themall, Prof Christopher Williams. A unique character is a fair way to describe him, but he isacknowledged as having been the best of thebest when it came to ileo-colonoscopy training.Simon Murch, John Fell and I learnt a greatdeal. We were in the mid-nineties, however,still iv drug users! Eric Hassall, the famousNorth American paediatric gastroenterologistand a good and wise friend, once wrote a paper‘Why pediatric endoscopists should not be ivdrug users.’ Referring to the dual role of performing a procedure and also administeringthe iv sedation. Holding down a child shouldnever be part of an endoscopy, nor shouldrespiratory rescue. ‘Let the anaesthetists dowhat they want to keep the child still, unknowing and amnesic and don’t get involved’ hasalways been my mantra. Cost and availabilityof anaesthetists is the only reason why it stillhappens in the bad old way.So I had a vision - please forgive me forsounding like a prima donna! The John WalkerSmith Unit had been running a brilliant PaedsGastro Course in December in London for atleast 12 years. As the young guy and the endoscopy enthusiast I thought ‘why not add on alive endoscopy day?’ John was very receptiveand the first one was a real experiment but itworked. I still owe Simon an apology for training the room camera on him as he was scopingand videoing his ‘gurnying’ (facial movementsas if in pain), during a live ileo-colonoscopy, to150 people in the main auditorium! Fortunately,he has a great and forgiving sense of humour.It was probably the first ever successful livepaediatric endoscopy meeting. The close interaction with scientists such as Alan Phillips alsocame out in this Course with biopsy orientationand handling adding another dimension. TheMeeting seemed, apparently, to work smoothly but a bit like a swan gliding serenely over thelake’s surface, meanwhile its legs swimmingfrenetically beneath, we were frantically tryingto get all the pieces of the jigsaw to fit togetherand at the appropriate time. It was amazing anda real privilege to be able to invite the great andgood from the world of paediatric endoscopyover to London to teach over the next 10 years Victor Fox, Luigi Dall’Oglio, Jean-FrancoisMougenot, Jean-Pierre Olives, Sami Cadranel,Yvan Vandenplas, Ernie Seidman, HarlandWinter, Athos Bousvaros, Raoul Furlano and ofcourse Eric Hassall. Other giants of the field Iwas to meet later.Over the next ten years we worked closelywith the adult GI Unit and Prof Owen Epsteinand I produced a DVD with over 400 endoscopyvideos and stills, which is still available andremains for me a great resource for Powerpointpresentations etc. This textbook has many othervideos on the accompanying webpage if you arexi

xiiPersonal statementsinterested. The Paediatric Endoscopy Unitevolved and we started pioneering therapeutictechniques with close clinical governance, andalways learning from meetings such as theBSG, ESGE, UEGW, and DDW which showcased new and exciting techniques in endotherapy. The Unit did however produce anon-endoscopy virtue - a wife and our firstdaughter - Kay was a part of our team at middlegrade level for a while which is how we met(Mills and Boon or not!) and I remain so grateful that she threw her towel in with me!Eventually the ‘pull to the North’ becameoverwhelming for me - back to where I grewup - and in 2004 I took the difficult and painfuldecision to leave John, Alan, Simon and Roband move to the relative peds GI virgin territory of Sheffield Children’s Hospital. Back to‘God’s Own County’, Yorkshire. Thanks to Kay,my incredible and long-suffering partner foragreeing and sacrificing her promising careerin ‘Pharma’ to which she had made a transferand a name for herself in a short time. I appreciate it more than you can know.So, now a blank canvas - almost. Prof ChrisTaylor was the only paeds GI there when Iarrived on, fittingly, April the 1st 2005. Iremember that in the very first list I broke theironly colonoscope! Oops! Time to get somemore then. . . . . . .Chris was a very generous host and indulgedmy ambitions. He was even kind enough as webecame friends to ask me to be his best manand I was delighted - only embarrassing himslightly.In 2005 we carried on with the Royal FreeCourse but then transferred it to Sheffield theyear after and converted it to a Hands-On smallgroup ileo-colonoscopy Course over 2–3 days.This was to be the template for the nest15 years and has increased in frequency drivenby demand to about 6–8 a year.Meanwhile we began to build the Unit andwith my colleagues and friends we have nowover 50 staff. Prof Chris Taylor and ProfStuart Tanner (hepatology) retired (Chrisonly recently) and I was joined by consultantcolleagues Sally Connolly (now also retired),David Campbell, Prithviraj Rao, Priya Narula,(temporarily Dalia Belsha, Franco Torrente andCamilla Salvestrini), Arun Urs, NataliaNedelkopoulou, Shishu Sharma, Zuzana Londt,Intan Yeop and Akshay Kapoor. Amazing teamwho all bring something different to the table.The Gastro Nurses are so important to us ledvery ably by Valda Forbes. Dietitians also brilliant led by Lynn Hagin, SALT by Jane Shaw,and psychology by Charlotte Merriman are alsohugely important and fantastic. Prof MartaCohen, head of histopathology and I have collaborated on research over the years and she isalways energetic and a great colleague to have.The people of Sheffield and the region are,contrary to popular belief of a Yorkshiremanbeing a ‘Scotsman robbed of his generosity’,incredibly generous. The Sheffield Children’sHospital Charity (led by my friend DavidVernon-Edwards) were, and have been, pivotalin financial help to make the Unit the mostfantastic place to work - the Endoscopy Unit ofthe Future, the double balloon enteroscopy setup, the wireless capsule endoscopy service andthe new magnetic-controlled capsule technology, and most recently the Symbionix virtualendoscopy training simulator, are amongst afew of the things that they have kindly andgenerously funded for us, allowing us to stay atthe cutting edge of training and diagnostic andendo-therapeutic capability.An area that I am particularly happy withis the ESPGHAN Council’s open-mindedapproach to the Endoscopy Special InterestGroup initiatives in terms of Training.Hands-On Courses are spreading, the Endos copy Learning Zone at the Annual Meeting hasbeen fantastic and is going from strength tostrength under the guidance now of Prof RaoulFurlano, and the first ever live endoscopy session occurred in 2019 in Glasgow at the AnnualESPGHAN Meeting and was very well received.There is nothing like performing live endoscopy to 500 people to get the cardiovascularsystem energised! Thank you to the recentPresidents of ESPGHAN Raanan Shamir and

Personal statementsthe ever-enthusiastic Sanja Kolacek. Sanja haspushed for, and obtained funding for, theESPGHAN Pediatric Endoscopy Fellowshipswhich are starting in early 2021, which willbe amazing - thank you!My endoscopic ‘raison d’être’ is to attempt toput the paediatric surgeons out of work! Hencepushing the boundaries in such areas as arecovered in this Textbook. Nevertheless, I thinkit is critical that we work hand in hand withour surgical colleagues, many of who performendoscopy, in order to blur the interfacebetween our approaches. I am extremely fortunate to work with some fantastic and enlightened individuals in the surgical team and weare almost a joint Unit nowadays – as can beseen by our innovations with laparoscopicassisted endoscopic percutaneous jejunostomyand duodenal web division, amongst manyothers. Maybe I am a frustrated surgeon afterall! Hopefully the web page is educational tothose that access it with many videos etc. I amparticularly indebted to the open-mindedattitude and team-spirited nature of Mr SeanMarven, Mr Richard Lindley, Prof Ross Fisher,Mr Suresh Murthi, Prof Prasad Godbole,Ms Emma Parkinson, and more recently Ms LizGavens and Ms Caroline McDonald. Sparringwith Jenny Walker was always fun and we arenow good friends. Rang Shawis and JulianRoberts should not be missed out here.Endoscopy in the modern world in childrencould not occur - especially endo-therapeutic without the excellence of our anaesthetists my stars are Dr David Turnbull, Dr Liz Allison,Dr Kate Wilson, Dr Rob Hearn, Dr GeorgeColley at the Royal Free, and most importantlyof all, the best paediatric anesthetist of themall, Dr Adrian Lloyd-Thomas (AL-T). A quickstory - the modern practice of topical application of Mitomycin C after esophageal dilationcame from a chance conversation with AL-T,who told me that the ENT guys used MitomycinC post-laryngeal reconstruction to prevent circumferential stenosis - we tried it and it workedin the esophagus of a girl requiring multiplefrequent esophageal dilation. Cue a paper inThe Lancet. Perhaps we should have morecross-specialty conversations?We should remember that this is the onlytruly ‘procedure-specific’ paediatric specialtyand stick to our guns with respect of the importance of endoscopy in our training. TheGuidelines and Position Papers, some jointwith ESGE and NASPGHN have beenextremely well received and, in addition, havehelped in raising the JPGN Impact Factor to itsnew dizzying height of nearly 3.Medicine is a vocation amongst us of course,and training the next generation has been oneof my major aims. In this I am particularlygrateful to Prof Sanja Kolacek in her unswerving support and application of her considerable energy in moving forward the recentamazing ESPGHAN Endoscopy FellowshipProgram - worth mentioning again!We should, in my view, never compromiseon the quality of training or care deliveryafforded by paediatric endoscopy by those ofus fortunate enough to have benefitted by it inour careers. Adult GI endoscopists should beinvolved only if we cannot avoid it - that comesdown to our learning the correct skills andtechniques and making their involvementredundant. We still have plenty to learn fromthem though, I will acknowledge.Recently we have created a global com munity for Pediatric Endoscopy - adult GI,European, North American, South American,Asian, Australasian Peds GI - and JointEndoscopy Guidelines have emerged – this isfantastic and I am sure that this fruitful collaboration will continue. Special mentionshould go to the drivers of these collaborativeefforts and the contributors - Catharine Walsh,Doug Fishman, Jenifer Lightdale, Jorge AmilDias, Andrea Tringali, Mario Vieira, RaoulFurlano, Victor Fox, Looi Ee, Patrick Bontems,Matjaz Homan, Rok Orel, Frederick Gottrand,Alexandra Papadopoulou, Salvatore Oliva,Erasmo Miele, Claudio Romano, LuigiDall’Oglio, Rob Kramer, Mike Manfredi, DianaLerner, Marsha Kay, Tom Attard, Warren Hyer,Joel Freidlander, ‘The Richards’ Hansen andxiii

xivPersonal statementsRussell, David Wilson, Dan Turner, Pete Gillett,Pat McKiernan, Stephen Murphy, ChristosTzivinikos, Ari Silbermintz, Rupert Hinds,Marta Tavares, Bruno Hauser, Yvan Vandenplas,Ron Bremner, Pete Lewindon, Petar Mamula,Orin Ledder, Merit Tabbers, Ilse Broekaert,Cesare Hassan, Marc Benninga, AlessandroZambelli, Nikhil Thapar, Iva Hojsak, StefanHusby, Ilektra Athiana, Andreia Nita, SaraIsoldi, Paola DeAngelis, Lissy De Ridder, theincomparable Samy Cadranel, all in theSheffield Team and many many more - apologies if I have missed you out!Thank you to the numerous members of theendoscopy Companies that have been so helpful over the years with Courses etc etc. You willknow who you are but to numerous to mentionhere.Kevin and Kat in ESPGHAN Head Officehave always been very receptive to any Qsneeded and I am grateful to them.There is no ceiling to what we can achieve inpediatric endoscopy. Attending ‘adult’ GI andendoscopy meetings is illuminating e.g. ‘ESGEDays’. We are no longer the Cinderella part ofpediatric GI but we still need to achieve paritywith the adult Societies - a place at the ‘toptable’ i.e. Societal Councils – as occurs in alladult GI Societies.I would like to thank all the trainees from somany countries and backgrounds for their personal commitment and sacrifice over the last25 years in coming to train with us - it neverceases to amaze me how mothers and fathersand spouses can leave their loved ones formonths, on occasions a year or more, in orderto train in this fantastic compelling area. Theirability to do so has been facilitated by myamazing Endoscopy Fellow and CourseCoordinator, without whom it would havebeen truly impossible to run such a successfultraining program - Sam Goult. Thankyou Sam.And then, if you have got this far then ‘welldone’. It is so important to me to hold up myhand and say that, in all honesty, I could havenot done all that I have done (admittedl

44 Endoscopic bariatric approaches 387 Mike Thomson and Matjaz Homan 45 Over-the-scope clip and full-thickness resection device 393 Mike Thomson 46 Endoscopic treatment of gastrointestinal bezoars 397 Andreia Nita and Mike Thomson 47 Natural orifice transendoluminal surgery 401 Mike Thomson Index 403