cadc-endoscopyEndoscopy -- 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 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 acute or chronic pancreatitis (short-term or long-term 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.

Specialists at NewYork-Presbyterian Hospital have extraordinary expertise and experience performing the full spectrum of advanced endoscopic procedures to diagnose and treat disorders of the digestive tract.

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 once used only to diagnose and stage disease, to one we can now use to treat patients.

 

Endoscopic Retrograde Cholangiopancreatography is a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-rays and the use of an endoscope. The scope is guided through the patient's mouth and throat, then through the esophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an x-ray.
If a duct is blocked, the physician can open it up by inserting a tiny stent (slender tube) into the duct through the endoscope, which can remain in place to keep the duct open. The physician may also take a small biopsy of tissue.
Before having ERCP, patients fast for 12 hours. They receive a sedative and anesthesia, before undergoing ERCP. The procedure itself requires about an hour.

If a duct is blocked, the physician can open it up by inserting a tiny stent (slender tube) into the duct through the endoscope, which can remain in place to keep the duct open. The physician may also take a small biopsy of tissue.

Advanced applications of ERCP that are performed include:

Endoscopic ultrasound (EUS)-assisted ERCP

This approach combines two endoscopic procedures to perform interventional treatments, such as clearing of a blockage in a bile duct. First, an "echoendoscope" is inserted into the patient's mouth and throat, which uses high-energy sound waves to locate the obstruction and the opening of the bile duct. Then ERCP is used to place a metal or plastic stent to open the obstruction.
EUS-guided ERCP is also useful when there are either anatomic abnormalities that don't make it possible to use standard ERCP, such as intestinal pouches near the union of the pancreatic and common bile ducts, or when the intestines have been redirected after surgery (which often happens after weight loss surgery, peptic ulcer surgery, and certain other gastrointestinal operations). In addition, sometimes conventional ERCP is difficult or impossible to perform when a tumor is completely obstructing the bile duct or its entrance.

Single-balloon ERCP

This imaging procedure uses endoscopy with overtube assistane to go examine the small bowel further than the standard endoscope.  The overtube has a balloon attached to it and when inflated, the balloons cling to sections of the small intestine and pleat it over the endoscope, effectively "shortening" it. Shortening of the small intestine over the endoscope lets the doctor undertake a comprehensive examination of the entire small intestine and makes biopsies, injections, and other treatments in the small intestine possible, including ERCP without surgery.
 

Surgery for weight loss remains a key strategy for treatment of obesity, but more options are emerging for management of this disease. Our weight loss surgery programs work alongside medical and nutritional strategies, with multiple specialists working together to decide the best course of action for each patient. In certain patients where diet and exercise are unsuccessful but surgery is not recommended or not an option, endoscopic options for treating obesity are available.

One such treatment is the intragastric balloon system, where an endoscopist places and inflates a small balloon within the stomach, reducing the volume of food that can fit into the stomach at a given moment. Designed for short-term use of six months or less, the intragastric balloon can help patients lose more weight than diet and exercise alone.

The intragastric balloon procedure is designed for patients who are not morbidly obese, but also may not be able to undergo bariatric surgery. Patients must meet the following criteria to be considered for an intragastric balloon:

  • Patients must have a body mass index (BMI) between 30 and 40
  • Candidates may not have had prior gastrointestinal or bariatric surgery
  • Candidates must be unable to lose weight through diet and exercise
  • Candidates must be willing to continue diet and exercise after the procedure, supervised by a healthcare provider
  • Candidates for this procedure cannot have certain comorbidities, including hiatal hernias, motility disorders, bleeding or clotting disorders, structural abnormalities or masses in the esophagus or stomach, psychiatric illness, most liver diseases, or various other conditions
  • Candidates for this procedure cannot take various medications that irritate the stomach, including aspirin, anti-inflammatory drugs, or anticoagulants

How the Intragastric Balloon Works

The intragastric balloon takes up space within the stomach, limiting the amount of food a patient can consume at any given meal. To place the balloon, a specially-trained gastroenterologist uses an endoscope to advance the uninflated balloon through the mouth and down the esophagus. After the balloon is in place, it is filled with saline, expanding to the size of a softball or grapefruit. Patients are placed under sedation for the balloon placement, and generally go home the same day as the procedure. Patients must follow a liquid diet for a brief amount of time after the procedure before resuming food consumption.

Both our gastroenterologists who place intragastric balloons and our bariatric surgeons work closely with a team of other providers including an endocrinologist and registered dietitian to monitor one’s food intake and metabolic health before and after the procedure. Diet and exercise are crucial after the procedure, even after the balloon is removed at the six-month mark.

Intragastric Balloon Outcomes

Clinical studies of the intragastric balloon indicate it can help patients lose more weight than with diet or exercise. Studies on this weight loss strategy indicate that patients who receive intragastric balloon coupled with behavior modifications such as improved diet and exercise can lose over two times as much weight after 12 months than people who simply follow behavior modifications. Patients losing more weight with the intragastric balloon also reported better quality of life on several metrics versus non-balloon patients, including bodily pain, social functioning, role functioning and vitality.

We value the ability to provide as many available treatment options to its patients as possible. Alongside bariatric surgery and endoscopic sleeve gastroplasty, the intragastric balloon offers another option to patients needing weight reduction. The support of a multidisciplinary team at NewYork-Presbyterian Hospital allows for more successful outcomes for patients.

We perform magnetic resonance cholangiopancreatography with secretin stimulation to assess pancreatic function and morphology of the pancreas in patients with pancreatic disease.

New techniques have been developed that allow for removal (or resection) of difficult polyps or even early superficial cancers throughout the GI tract. The goal for removal of these type of lesions are to remove the entire lesion in one piece, and to cut deep enough below the abnormal tissue without going through the muscle layer which would  cause a hole called a perforation. In this procedure, a thick fluid is injected below the abnormal tissue into the submucosal layer (between the mucosa and the muscles layers) and the mucosa is lifted creating a cushion underneath. An incision is made in the mucosa in order to expose these submucosal fibers, which are then dissected using special electrosurgical instruments. During the dissection, small blood vessels may be seen and are cauterized in order to prevent bleeding or to help control bleeding that might occur.  By dissecting the submucosal tissue away from the muscle layer, the abnormal tissue above it is freed and can be completely removed. This allows for curative removal of pre-cancerous or even some cancerous lesions without having to perform surgical removal of an entire segment of the GI tract, known as “organ-sparing resection”. ESD can be performed anywhere along the GI tract including the esophagus, stomach, duodenum, colon and the rectum.  

Sometimes, the submucosal layer has too much scar tissue or the tumor may involve the muscle layer. In most cases, this means that the tumor is more advanced and these should be evaluated for surgical removal. In some cases, however, some patients may not be able to undergo surgery because of other medical conditions. In these cases, removal of the tumor is still possible through a procedure called full thickness resection using special dedicated devices and techniques.

ESD is a form of submucosal endoscopy or “third-space endoscopy” because the endoscopist is working within the wall of the GI tract. By accessing this submucosal space, interventional endoscopists can now access structures and tumors that previously required surgical access from the outside inwards. For example, using third-space endoscopy, small tumors that are within the wall of the esophagus or stomach, called submucosal tumors, can now be removed while leaving the wall intact. Similarly, the layers within the GI tract, such as the muscle layer can be accessed in order to perform some therapeutic procedures in which the muscle layer needs to be disrupted or cut.

One third space endoscopy procedure is called Peroral endoscopic myotomy (POEM) and is a technique that involves tunneling between the muscle layers of the esophagus to treat achalasia, a motility disorder of the esophagus. Achalasia prohibits or reduces the ability of the muscles that make up the lower esophageal sphincter (between the esophagus and stomach) to relax. There are multiple different treatments for achalasia but the most definitive is cutting or disrupting the muscle layer (myotomy). A POEM procedure is when this cutting is performed completely through endoscopic methods, and no incisions on the skin are made.

During a POEM procedure, an endoscope is passed through the mouth, and upon reaching the esophagus, an incision is made through the esophageal wall to expose the submucosal tissue (the layer between the mucosa and the muscle layer. A tunnel is then created in the submucosal layer all the way down to the level of the stomach, exposing the muscle fibers for the length of the tunnel. When the end point of the tunnel is reached, the muscle layer is then cut (myotomy). At the end of the procedure, the initial incision in the first layer of the esophagus is secured closed, preventing anything from leaking outside. By cutting the muscle, the entry of food and drink to the stomach from the esophagus is significantly improved.

Patients are required to fast for 12 hours before the procedure, making sure that the upper gastrointestinal tract, namely the esophagus, is clear of any food or food residue. Patients are admitted for the POEM procedure, which usually takes 2 to 3 hours. A barium contrast study is performed after the procedure to confirm there is no leak and patients are able to return to a liquid diet with progression to normal diet over the span of a few days.

Quick recovery and high success rates mark some of the benefits of peroral endoscopic myotomy for patients with achalasia, ,which can allow patients able to swallow normally sometimes within 24 to 48 hours. POEM can also be used to perform other motility disorders of the esophagus that may require more extensive cutting of the muscle, such as Jackhammer esophagus.

G-POEM

The POEM procedure can also be performed in the stomach, referred to as a G-POEM, in order to treat a motility disorder of the stomach known as gastroparesis. In a G-POEM, the muscle bundle that is targeted to be cut is the called the pylorus and is the opening of the stomach to the small intestine. The same sequence of steps are taken in the stomach as in the esophagus, however, the length of the tunnel and the myotomy are shorter. Confirmatory contrast studies are usually not required after the procedure.

This treatment method is used to open up esophageal or biliary blockages or treat small, shallow tumors in patients who cannot tolerate open surgery. In PDT, a drug called a photosensitizer is given to the patient intravenously and absorbed only by cancer cells over a few days. Using an endoscope, the surgeon exposes the lesion to a certain wavelength of light, which causes an active form of oxygen to be produced. This directly kills the cancer cells and also acts indirectly to damage the tumor's blood vessels, further destroying the cancer and limiting damage to surrounding healthy tissue.

PDT cannot be used for large or deep tumors. Risks include light sensitivity for about six weeks after treatment, trouble swallowing after treatment, swelling, pain, or scarring in healthy tissue. The endoscopist may also place a stent in the esophagus to open up any blockage and enable more comfortable swallowing.

This treatment method is used to open up esophageal or biliary blockages or treat small, shallow tumors in patients who cannot tolerate open surgery. In PDT, a drug called a photosensitizer is given to the patient intravenously and absorbed only by cancer cells over a few days. Using an endoscope, the surgeon exposes the lesion to a certain wavelength of light, which causes an active form of oxygen to be produced. This directly kills the cancer cells and also acts indirectly to damage the tumor's blood vessels, further destroying the cancer and limiting damage to surrounding healthy tissue.

PDT cannot be used for large or deep tumors. Risks include light sensitivity for about six weeks after treatment, trouble swallowing after treatment, swelling, pain, or scarring in healthy tissue. The endoscopist may also place a stent in the esophagus to open up any blockage and enable more comfortable swallowing.

This procedure is used to open the sphincter draining the pancreas or bile duct from the inside, via a small catheter placed through an endoscope. This is a very effective procedure used to facilitate stone removal or stent placement.

Endoscopic stenting of many sites along the gastrointestinal tract can be performed successfully for malignant or benign obstructions. These obstructions may be the result of primary gastrointestinal tumors invading the lumen, tumors of another primary site causing external compression, or in some instances benign diseases associated with inflammation.

These stents resolve the obstruction or improve symptoms and are often used as first-line therapy as an alternative to a feeding tube insertion or surgery. In the case of blocked bile and pancreatic ducts, the stent can be inserted via an endoscope during endoscopic retrograde cholangiopancreatography (ERCP). For patients with colon cancer, the stent is inserted via an endoscope inserted into the rectum. For stent placement in the small bowel, the stent is inserted via an endoscope into the duodenum.

Stents can also be placed before chemotherapy or as a "bridge" to surgery in patients who need to gain weight (such as those with esophageal cancer) or receive a preparation (such as those with colon cancer). Clinical trials are currently ongoing on novel stent designs for various sites in the digestive lumen.

We employ a variety of approaches to remove or destroy stones in the biliary and pancreatic ducts, depending on their size and location. These include:

Choledochoscopy

Doctors use this approach to directly visualize the biliary tract using A “scope within a scope”. Small stones can be removed from the common bile duct during this procedure using laser therapy or electrohydraulic lithotripsy.

Pancreatoscopy

A small camera is placed inside the pancreatic duct to assess lesions, perform biopsies, and treat stones.

Lithotripsy of bile duct stones

Our doctors use high-energy shock waves or lasers to break up stones in areas such as the bile and pancreatic ducts.

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NewYork-Presbyterian/Weill Cornell Medicine

Center for Advanced Digestive Care

NewYork-Presbyterian/Columbia

Division of Digestive and Liver Disease