Understanding Advanced Endoscopy!

Understanding Advanced Endoscopy!

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By Dr. Tarun Bharadwaj, Gastroenterology

1.ENDOSONOGRAPHY

Endosonogaphy is an advanced imaging and therapeutic technique which has revolutionized the management of patients suffering from pancreaticobiliary disorders. Echoendoscope is a flexible tube and on its tip ultrasound transducer is placed for imaging organs close to the GI tract. Due to its high sensitivity and resolution, EUS is better than transabdominal ultrasound in selected cases. EUS has the capability of imaging the entire pancreas, gall bladder, bile duct and ampullary region along with mediastinum for the presence or absence of suspected pathology. The patient is usually sedated and is performed on a daycare basis. Although a safe and very effective technique EUS still has its own procedure-related risks. Prior to the procedure the gastroenterologist will discuss with the patient and their relatives the benefits, risks, alternatives and technical details of EUS. The patient is in the left lateral position and the echoendoscope is passed under the vision for examination. Depending on the indication the procedure may require 5 to 15 minutes.

Diagnostic indications of EUS

1. Evaluation of biliary pain and suspected CBD stone

2. Evaluation of dilated CBD and obstructive jaundice

3. Evaluation of Liver metastasis and space occupying lesions of liver

4. Evaluation of gall bladder polyps, stone and cancer.

5. Evaluation of early chronic pancreatitis and recurrent acute pancreatitis

6. Evaluation of peripancreatic fluid collections for location, size and feasibility of drainage.

7. Evaluation of cysts in pancreas and masses (pancreas cancer)

8. Evaluation of abdominal and mediatinal lymphadenopathy (benign or malignant lymph nodes)

9. Evaluation of malignant ascites and thickened peritoneum.

10. Evaluation of gastric fundal varices

11. Staging of pancreatic malignancies,vascular involvement and feasibility of surgery.

Therapeutic indications of EUS

1. EUS guided FNAC from lymph nodes and masess for establishing diagnosis

2. EUS guided drainage of peripancreatic fluid collections(Pancreatic pseudocysts in acute/chronic pancreatitis)

3. EUS guided choledochoduodenostomy and hepatico-gastrostomy for palliation of advanced pancreato-biliary malignancies.

4. EUS guided Rendezvous in case of failed ERCP

5. EUS guided fundal varices Coiling for effective obliteration

2. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY(ERCP)

 ERCP is the technically challenging and advanced procedure for the management of the pancreaticobiliary disease. ERCP is performed in the left lateral, prone or supine position with the patient sedated. Duodenoscope (Side viewing endoscope) is passed under the vision to focus on ampulla in the second part of duodenum. Based on indication and patient problem, biliary or pancreatic duct is cannulated with the help of guidewire and Endotherapy is performed. In expert hands, the procedure is safe but still has significant risks. Prior to the procedure, the gastroenterologist will discuss with the patient and their relatives the benefits, risks, alternatives and technical details of ERCP. Informed consent is taken from the patient about ERCP. The patient may require admission in a hospital prior to or after the ERCP for fitness or monitoring.

Indications for ERCP

With the availability of EUS and MRCP/CT scan, diagnostic ERCP is no longer performed. ERCP has the following therapeutic indications-

1. CBD stone (Choledocholithiasis) extraction and stenting

2. Management of Postcholecystectomy bile leak

3. Plastic stenting or Covered metallic stenting for benign biliary stricture

4. Self-expanding metallic stenting (SEMS) for inoperable Pancreato-biliary malignancies such as advanced gall bladder cancer, unresectable cholangiocarcinoma and pancreatic cancer.

5. Spy Cholangioscopy with LASER Lithotripsy for difficult/Large stones

6. Pancreatic stone removal and stenting for pain relief in chronic calcific pancreatitis

7. Pancreatic sphincterotomy and stenting for transpapillary peripancreatic fluid drainage

8. Pancreatic sphincterotomy and stenting for post-traumatic pancreatitis and pancreatic ductal leak.

9. Pancreatic endotherapy for recurrent acute pancreatitis in Pancreas divisum.

10. Removal of proximally migrated pancreatic-biliary stents.

11. Plastic stenting in acute cholangitis for urgent biliary decompression