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Advanced Endoscopy Enables Doctors to Relieve Obstructions

New York (Nov 1, 2011)

Drs. Michel Kahaleh and John Poneros
Michel Kahaleh, left, and John M. Poneros,
right, are using endoscopes for digestive
procedures.

Endoscopy – the use of a long, flexible tube with a camera at its tip to peer inside a patient – has been used to help doctors assess and diagnose disorders of the digestive tract. Now "interventional" advances in endoscopy are making it possible for them not only to see what's going on, but to treat the disorder – such as opening up obstructions in the ducts linking the liver with the intestine and gallbladder, as well as ducts coming from the pancreas.

Such obstructions may develop as a result of cancer – including bile duct cancer and pancreatic cancer – and from pancreatitis (inflammation of the pancreas). These obstructions can cause significant pain, jaundice (yellowing of the skin), and other symptoms, such as fever and itchy skin, which impair quality of life.

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During endoscopy, a scope is gently inserted down the patient's throat to visualize the area of interest within the digestive tract. Interventional endoscopy takes this approach steps further by incorporating other equipment the doctor can use to open up obstructions (such as cancer tissue, inflammation, or stones), drain fluid, or destroy precancerous tissue. "Interventional endoscopy has gone from a technique we once used only to diagnose and stage disease, to one we can now use to treat patients," said Michel Kahaleh, M.D., A.G.A.F., F.A.C.G., F.A.S.G.E.

Many of the recent advances rely on new imaging approaches. "We use radiology as a roadmap," added Dr. Kahaleh. "A CT scan or MRI provides us with an image of the problem, allowing us to offer the best therapeutic intervention."

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That was the case in two recent procedures performed by interventional endoscopy specialists led by Dr. Kahaleh, who used a technique called "endoscopic ultrasound (EUS)-guided endoscopic retrograde cholangiopancreatography (ERCP)" to relieve bile duct obstruction in an elderly man caused by a tumor measuring four by five centimeters in size and a patient with a large duodenal diverticulum preventing biliary access. Both patients were adequately decompressed and have returned home. It was the first time those procedures were performed at NewYork-Presbyterian/Weill Cornell.

First, an echoendoscope was inserted into the patient's mouth and throat, which used high-energy sound waves to visualize the level of obstruction and degree of bile duct dilation. After puncturing the bile duct with a small needle and placing a wire crossing the obstruction from inside the occluded bile duct ( Figure 1) ERCP, which combines x-rays and contrast injection, is used to place a metal or plastic stent ( Figure 2-3 ). These were cases where ERCP cannot be performed and ordinarily these patients would have gone to surgery. But with these advanced endoscopic techniques surgery can be avoided and the procedures can be performed less invasively. Examples of when this technique is useful are when there are either anatomic abnormalities precluding ERCP such as difficult periampullary diverticula or when the intestines have been rerouted after surgery (as is the case oftentimes after bariatric surgery, peptic ulcer surgery, s/p Billroth or Roux en Y operations). In addition, sometimes ERCP is difficult or impossible when a tumor is completely obstructing the bile duct or entrance to the bile duct (advanced pancreatic cancers causing duodenal obstruction, ampullary cancers, etc.).

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"The treatment of patients with pancreatic and biliary diseases can be highly complex," explained John M. Poneros, M.D., who leads the interventional endoscopy team at NewYork-Presbyterian/Columbia University Medical Center, which includes Amrita Sethi, M.D. and Tamas Gonda, M.D. "The diagnostic and therapeutic approaches necessary to manage these conditions may require skills and support that are beyond the scope of care offered by many community-based gastroenterologists. Interventional endoscopy teams at major academic medical centers have the expertise and resources required to assess and treat patients with these often complicated disorders."

At NewYork-Presbyterian, doctors also use ERCP to examine patients with gallstones, pancreatic cancer, and pancreatitis. They can also employ it to drain a complication of pancreatitis called a "pseudocyst."

As the population ages, it is expected that the incidence of disorders affecting the pancreas and bile ducts may rise. "Our patients are increasingly looking for less invasive ways to relieve their pain and discomfort," concluded Dr. Kahaleh. "Interventional endoscopy enables us to meet their needs in a noninvasive way."

Contributing faculty for this article:

Michel Kahaleh, M.D., A.G.A.F., F.A.C.G., F.A.S.G.E., is the Chief of Advanced Endoscopy at NewYork-Presbyterian/Weill Cornell Medical Center and a Professor of Medicine at Weill Cornell Medical College.

John M. Poneros, M.D., is the Interim Director of Endoscopy at NewYork-Presbyterian/Columbia University Medical Center and an Assistant Professor of Medicine at Columbia University College of Physicians and Surgeons.

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