This text provides a comprehensive review of the ethical issues involved with the development, evaluation, and introduction of new treatments of gastrointestinal diseases. How several landmark surgical innovations were developed are described to show the challenges faced, and the ethical dilemmas these innovators dealt with. The challenges of dealing with regulatory issues, and how to work with industry partners, and investors when working on a new therapy is described. Once a new technology has been brought to the market, standards need to be developed regarding the training, credentialing and adoption of the new technology. There are insufficient standards of how to balance the desire to provide patients the latest therapy with the obligation that patients receive informed consent about the new technology, and the relationship that the physician may have had with product development. The book describes the national perspective of paying for new technology, and provides one insurance company's approach to the introduction of innovative therapy. The Sages Manual Ethics of Surgical Innovation will be a resource for surgeons, researchers and health policy personnel to understand the ethical issues related to the development, introduction and adoption of innovative therapies for gastrointestinal diseases. Although the context for discussion is the application of innovation to gastrointestinal disease, the ethical issues are applicable to any discussion of innovative medical or procedural therapies.

Gastrointestinal bleeding is an age-old problem. The original description of g- trointestinalbleedingmayhavebeenfromGalenandhisworkconnectingdyspepsia andmelanoticstool. Thechangesinourmanagementofgastrointestinalbleeding overthecenturieshavebeendrivenbynaturalalterationsinthespectrumofdiseases, expanding our understanding of these diseases and the never ending advances in technologyandpharmacologythathaveoccurredrelativetoGIdiseases. Academic interestingastrointestinalbleedingpeakedinthelasthalfofthetwentiethcentury withtheexpandingroleofsurgery,thediscoveryofacid-basedpepticulcerthe- pies,andtheriseof?exibleendoscopyandculminatedinthedescriptionofh. pylori as a causative agent for ulcer disease. More recently there has been a decrease incidenceinbleedingdiseasesofthegutandthereforeadecreasinginterestinthe scholarlywritingaboutthesediseases. Therehasnotbeenamajortextbookwritten aboutgutbleedinginover10yearsandthereforetheintentionofthistextbookisto ?llthatvoidbyprovidingareviewofacomprehensiveapproachtouppergut,mid, andlowergutbleeding. CliniciansatDukeUniversitywhohaveacommoninterestinthegastrointes- naltracthavecollaboratedintheconstructionofthistext. Thisefforthasbrought together surgeons, gastroenterologists, and radiologists, to carefully chronicle the presentation, diagnosis, and management of modern day causes of gastrointes- nal bleeding. These co-authors concentrate on some of the latest innovations in the endoluminal and minimally invasive techniques that characterize the current approaches to these diseases. Emphasis has been placed on capsule endoscopy, double-balloon endoscopy, laparoscopic peptic ulcer surgery, and angiographic diagnosis and management techniques. The text has been written in such a way thatthereadercanquicklyreviewaspeci?ccauseofGIbleedingpriortomanaging ofsuchapatient. Weexpectthistextwillbeusedwiththesameimmediacyasthe diseasespresent. Wehopethatthistextprovidesafoundationforlearningformedicalstudents, interns,residents,andpractitionerswhoencounterthesecriticallyillanddif?cultto managepatients. Durham,NC,USA AuroraD. Pryor Durham,NC,USA TheodoreN. Pappas Durham,NC,USA MalcolmStanleyBranch v Acknowledgment TheeditorswouldliketothankMs. VirginiaCashforherhelpinthepreparation andcoordinationofthetext. vii Contents Part I Upper GI Bleeding Stabilization of Patients Presenting with Upper Gastrointestinal Bleeding. ..3 ErrolL. BushandMarkL. Shapiro Urgent Workup for Upper Gastrointestinal Bleeding...13 LorettaErhunmwunseeandSandhyaA. Lagoo-Deenadayalan Management of Esophageal Variceal Bleeding ...23 KekiBalsaraandLisaPickett Management of Dieulafoy's Lesions ...31 SerainaK. Faes,BrianR. Untch,ClaireEdwards,JohnTurner, MartinPoleski,andDouglasS. Tyler Management of Bleeding Peptic Ulcer Disease ...39 JamesC. PadussisandTheodoreN. Pappas Management of Unusual Sources of Upper GI Bleeding...65 ElisabethTracyandJanetTuttle-Newhall Mallory-Weiss Syndrome...79 JacobN. SchroderandMalcolmS. Branch Management of Bleeding Small Bowel Tumors...85 KeriE. LunsfordandAuroraD. Pryor Management of Bleeding from the Bile Duct ...103 CarlosE. MarroquinandBridgetM. Marroquin Management of Bleeding from the Pancreas...