The present study tried to look at the practice of therapeutic endoscopy at a large medical center in Addis Ababa, Ethiopia. A total of 1769 patients underwent therapeutic procedures over 8 years. The majority (76.4%) of the patients in this study got endoscopic treatment for upper gastrointestinal disease. Of these patients, 97% of the patients were treated for esophageal varices. While1.8% of the patients were treated for fundal varices and only 1.1% of the patients were treated for bleeding duodenal ulcers. This is similar to a recent study in Ethiopia at St. Paul's Millenium Medical College in Addis Ababa, which reported that the most common cause of upper gastrointestinal bleeding was esophageal varices (16). However, studies done in the last two decades showed that the most common cause of UGIB in Ethiopia was duodenal ulcer (17, 18). This change in the etiology of UGIB can be attributed to the introduction of the appropriate use of H. pylori eradication therapy, as well as knowledge and awareness of the transmission dynamics of H. pylori (19). Similarly, multiple recent studies on upper gastrointestinal bleeding conducted in several African countries show that the most common cause of UGIB is esophageal varicies(20–23).
Most of the patients treated for UGIB were males in this study with a male to female ratio of 3.4:1. Similarly, multiple studies conducted in Ethiopia and other countries, showed male predominance among patients presenting with UGIB (7, 16, 24). This could be as a result of the disproportional predisposition of males to etiological factors that influence UGIB such as gastritis, PUD, and liver cirrhosis caused by viral hepatitis and alcohol abuse (21).
Published papers show that surgery was used to treat portal hypertension with bleeding esophageal varices in Ethiopia as recently as 2005 (25). EVL was started in Ethiopia in 2008 at the study center. In this study, 90 % f the patients with UGIB were treated with EVL, similar to a study from Nairobi, Kenya (26). EVL and sclerotherapy were both done for patients with esophageal varices to control actively bleeding lesions and/ or as prophylaxis for bleeding. Some studies show that both sclerotherapy and band ligation are effective in acute hemostasis of bleeding esophageal varices (27, 28). While other studies show that variceal band ligation is preferred due to its superior safety profile and shorter procedure time (27). Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. Nonetheless, most complications can also be managed with endoscopic interventions (29). On the other hand, other studies show that combined variceal ligation and sclerotherapy had less rebleeding rates and recurrence at six months and less chest pain and was more cost-effective compared to endoscopic variceal ligation alone in the treatment of gastroesophageal varices (30).
Upper gastrointestinal bleeding that cannot be controlled by a minimally invasive endoscopic procedure requires surgical intervention (31). However, in this study EVL and sclerotherapy were successful, and none of the patients required emergency surgical intervention for upper gastrointestinal bleeding. Similar to this study, a study conducted in Morocco showed a high rate of primary hemostasis achieved through endoscopic intervention in patients with upper gastrointestinal bleeding with 96.5 percent of patients being successfully managed (32).
Colonoscopic removal of polyps is shown to have a marked reduction in the rate of and mortality and morbidity associated with colorectal cancer (33–35). Polyps were removed using snares from the rectum (57%), colon (37.9%), gastric (4.1%), and rectosigmoid area (0.8%) at our center. Large colonic lesions could also be removed by endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR), with high success rates and acceptably low complications, reducing the need for surgery (35). However, the practice of such procedures in Ethiopia is limited and most patients end up requiring surgery.
Although, surgical procedures are done for gastrointestinal strictures are potentially curative, they are associated with high rates of morbidity and mortality. Several non-surgical, minimally invasive interventional endoscopic options are available to treat benign strictures of the esophagus and gastric outlet. These procedures include balloon dilation, temporary stent placement, intralesional steroid injection, and incisional therapy (36). At the medical center where the study was conducted, esophageal strictures are treated with balloon dilatation, followed by steroid injection, and temporary stenting with a success rate of 95.56%. A study done in Egypt on post corrosive esophageal strictures showed a less (78%) success rate than our study (37). Another study showed a primary efficacy of 98.8% among children with esophageal strictures (11). Endoscopic esophageal stricture dilatation is also safe & effective in children (11). In this study, 15.6% of the patients with esophageal stricture dilatation were below the age of 15. Most of the studies showed an efficacy rate of stricture dilatation ranging between 90 and 100% 12. Comparably, 95.56% of our patients that had endoscopic stricture dilatation reported symptomatic improvement.
Achalasia is most of the time treated surgically in Ethiopia (38). Definitive therapeutic options offered to patients vary, depending on access, resources, and expertise, and include pneumatic dilation (PD), laparoscopic Heller's myotomy (LHM), or per-oral endoscopic myotomy (POEM). LHM and POEM have been found superior to PD in terms of success (39). A recent study showed that 46% of patients treated with pneumatic dilation required repeat dilatation, whereas only 8% of patients treated with POEM required further treatment after 2 years (40). However, these therapeutic interventions are not available in Ethiopia,and patients are usually treated surgically, open transthoracic myotomy. Patients with achalasia who defer surgical treatment had endoscopic dilatation done for temporary symptomatic relief and showed improvement immediately after dilation, but the recurrence rate was 50% requiring surgical myotomy.
About 80–90% of the ingested non- sharp foreign bodies pass spontaneously through the gastrointestinal tract without complications, but in 10–20% of the cases, an endoscopic intervention is deemed necessary (41). Technological advancements in endoscopy have made it possible and safe for the extraction of GIT foreign bodies via endoscopy (42). Flexible Endoscopy is a very safe and efficient method of timely diagnosis and removal of ingested FBs in children and adults and it is the therapeutic method of choice for relieving food impaction and removing true foreign bodies with a success rate of over 95% and with minimal complications (41, 43). In our center, removal of swallowed foreign bodies was completed in 96.67% of the patients while one patient required surgical intervention due to prolonged impaction, and the bone piece was embedded in the esophageal mucosa. When endoscopic removal is challenging surgical intervention is needed to remove foreign bodies (44). Therefore, our patient was treated surgically. Unfortunately, he developed post-operative stricture, which was successfully dilated endoscopically. In this study, coins were extracted from children under the age of 15 similar to studies that revealed the most common ingested foreign body in children are coins (10, 45, 46)
From published studies, endoscopic band ligation has more success and is more cost-effective in treating patients with hemorrhoids as well when compared to sclerotherapy and hemorrhoidectomy (5, 47). Most (74.1%) of our patients were also treated with band ligation while only 25.6% of the patients were treated with sclerotherapy for hemorrhoids.
The strength of our study is that it is the first study in Ethiopia and one of the few in SubSaharan Africa, that tried to look into the practice of therapeutic endoscopy. Most previous studies have looked into clinical problems as well as the prevalence of certain conditions in a given population. In addition, the evidence base for the practice of such procedures is needed to justify investment in the field. By showing the practice and the outcome, our study aims to fill the gap in the available literature regarding therapeutic intervention practice in resource-limited setups, primarily in Sub-Saharan Africa. Stakeholder engagement, as well as investment in the field, are required to improve the practice of therapeutic procedures, as most of the accessories employed in these procedures require significant resources and manpower training.
Our study does have limitations too. The main limitation is that our study is retrospective in design and maintaining homogeneity interms of study variables is difficult. In addition, the important clinical, as well as laboratory profile of patients, was not consistently available to provide an overall better picture of findings. The other limitation of our study is that we tried to look into the practice of therapeutic endoscopy in general and details of some interventions were not assessed in depth. Some of the interventions reported require an in-depth analysis of certain parameters which is difficult to confine in this one report; however, the general description of findings would provide a stepping ground for further research in the area. Furthermore, practices of more advanced procedures like EUS and ERCP were not assessed in our study, as these procedures are not widely available hitherto in Ethiopia.