Do Pulmonologists Need to Tighten up Their Sphincter Tone? Do Pulmonologists Need More Guts?

delivering endoscopic therapies due to the higher incidence of gastrointestinal (GI) diseases (such as bleeding peptic ulcer) that are amenable to such therapeutic modalities. The other reason (and a more philosophical one) may have something to do with the basic characteristics of GI or pulmonary physicians. Could it be that the physicians who choose gastroenterology as a profession are more likely to take (calculated) risks than those who choose pulmonary medicine? In other words, are the GI folks ‘gutsier’ than the pulmonologists when it comes to performing procedures? This unfortunately seems to be at least in part true. Although pulmonologists do an outstanding job unravelling complex pulmonary cases, and have excellent command over pulmonary physiology and function, they seem to shy away from their bronchoscope, and appear to consider it as an awkward, diffi cult-to-handle instrument whose sole purpose is to make life more diffi cult for the patient and the physician. Surveys have shown that the majority of pulmonologists use the bronchoscope mainly for tissue diagnosis of a suspected pulmonary lesion, assessment of hemoptysis, and occasionally for identifying an infectious agent, or determining the cause for a patient’s interstitial lung disease. Only a minority uses the instrument for techniques that are unfortunately considered as ‘more elaborate’. For instance, only a quarter of pulmonologists ever perform transbronchial needle aspiration, while only 15% perform interventional techniques such as electrocautery or stenting [14] . Although reports on transbronchial needle injections (TBNI) were made as early as 1965, a systematic review of its application has only recently been reported by Seymour et al. [1] in this current issue of Respiration . This paper is an interesting and comprehensive overview of the published literature on the diagnostic and therapeutic capabilities of TBNI, with special emphasis on its role in the management of various pathological conditions using specifi c injectable agents. Surprisingly, TBNI has not gained much popularity amongst bronchoscopists, resulting in no randomized controlled trials that can effectively demonstrate its potential value as an armament in the pulmonologists’ fi ght against various respiratory diseases. In contrast, this technique is widely used effectively by our gastroenterology colleagues as a management modality for a variety of digestive tract diseases: ethoxysclerol [2] , human thrombin [3] , histoacryl [4] or polidocanol [5] for bleeding peptic ulcers, botulinum for achalasia [6] , Nbutyl-2-cyanoacrylate for pancreatic fi stulas [7] , inert implantable materials and non-resorbable copolymers for gastroesophageal refl ux disease [8, 9] , enbucrilate for mycotic aneurysms [10] , hydroxypropyl methylcellulose or photocrosslinkable chitosan for cancer or polyp resection [11, 12] , or alcohol, various anticancer agents and local immunotherapy for digestive tract cancers [13] , to mention a few. The reason for this disparity between gastroenterologists and pulmonologists is unclear. One may postulate that there are more gastroenterologists with expertise in

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