Types of Interventional Endoscopy Procedures
Interventional endoscopists at NewYork-Presbyterian have exceptional training and experience in using advanced techniques to diagnose and treat patients with a variety of digestive diseases.
Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure not available at every hospital. It is used to diagnose and treat liver, gallbladder, bile ducts, and pancreas problems. The procedure combines x-rays and the use of an endoscope. The scope is guided through the patient's mouth and throat, then through to the esophagus, stomach, and duodenum (first part of the small intestine). The physician can examine the inside of these organs and detect any abnormalities.
During ERCP, a tube is 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 remains in place to keep the duct open. The physician may also take a small biopsy of tissue. Advanced uses of ERCP include:
- Endoscopic ultrasound (EUS)-assisted ERCP. This approach combines two endoscopic procedures. First, an "echoendoscope" is inserted into the patient's mouth and throat, using high-energy sound waves to locate an obstruction and the bile duct opening. ERCP is then used to place a metal or plastic stent to open the obstruction. EUS-guided ERCP is also useful when there are anatomic abnormalities that don't make it possible to use standard ERCP.
- Single-balloon ERCP. This imaging procedure uses an endoscopy plus an "overtube" to examine the small bowel. The overtube has a balloon attached to it; when inflated, the balloon clings to sections of the small intestine and pleats it over the endoscope — making it easier for the doctor to examine, biopsy, and apply treatments to the small intestine without surgery.
Endoscopic ultrasound and fine-needle aspiration
Endoscopic ultrasound (EUS) involves using an echoendoscope to visualize the digestive tract and nearby organs. It is beneficial for evaluating the pancreas and is often used to guide fine-needle aspiration (FNA) — the insertion of a needle to withdraw a diseased tissue sample for analysis. EUS/FNA is a nonsurgical way to biopsy and stage pancreatic tumors and other digestive tract lesions. EUS can also be used to guide the placement of a stent to drain a pancreatic pseudocyst by connecting it to an adjacent intestinal organ.
Endoscopic weight loss procedures
If diet and exercise do not help you lose weight and are not ready for or able to have weight loss surgery, you may undergo an endoscopic weight loss procedure. These procedures are options for some people who are obese but not significantly obese (body mass index, or BMI, between 30 and 40). Examples include people who have a BMI of less than 40 without other medical problems; a BMI of 30-35 with high blood pressure, high cholesterol/triglycerides, type 2 diabetes, or sleep apnea; or large amounts of abdominal scarring from injuries or previous procedures which prevent surgery. NewYork-Presbyterian offers the following endoscopic weight techniques, along with guidance and support from our multidisciplinary weight loss teams of medical doctors and nutritionists:
- Endoscopic sleeve gastroplasty. The endoscopist advances an endoscope through your mouth into your stomach and inserts sutures in a specific pattern from the bottom of the stomach to the top. The sutures are tightened in an accordion-like fashion, reducing the amount of space in your stomach for food.
- Endoscopic intragastric balloon. The intragastric balloon takes up space within your stomach, limiting the amount of food you can eat during a meal. You may swallow the balloon, or the endoscopist may use an endoscope to advance the uninflated balloon through your mouth and down your esophagus. After the balloon is in place in your stomach, it is filled with saline or a special gas, expanding to the size of a softball or grapefruit. Diet and exercise remain important components of care after the procedure, even after the balloon is removed six months later. Studies show that this technique can help people lose more weight than with diet or exercise alone.
- AspireAssist device. This device is a thin tube inserted in your stomach that helps you empty the food from your belly after a meal, limiting the amount of food you absorb. The tube is inserted into your stomach through an endoscope and is connected from the inside of your stomach directly to a discreet button on the outside of your abdomen. The tube and device combination is attached when the "emptying" process begins. The entire device is the size of a smartphone and comes with a small stowaway case.
Submucosal "third-space" endoscopy
With "third-space endoscopy" techniques, the endoscopist works within the layers of tissue making up a digestive tract wall. NewYork-Presbyterian performs these procedures regularly and has amassed significant experience in their use. Examples include:
- Endoscopic submucosal dissection (ESD). To remove difficult polyps or early superficial cancers, a thick fluid is injected below the abnormal tissue into the submucosal layer (the layer of tissue between the inner lining of the digestive tract and the muscle layers), and the mucosa is lifted, creating a cushion underneath. The goal is to remove the polyp or tumor in one piece. Small tumors within the digestive tract wall can be removed while leaving the mucosa and muscle wall intact. ESD can be performed anywhere along the digestive tract, including the esophagus, stomach, duodenum of the small intestine, colon, and rectum.
- Peroral endoscopic myotomy (POEM). POEM is used to treat achalasia, a swallowing problem resulting from food's inability to move freely down the esophagus. Cutting of the muscle layer (myotomy) in the esophagus is the most effective treatment for achalasia. During POEM, the endoscopist passes the endoscope through the mouth and into the esophagus, where an incision is made through the esophageal wall to expose the submucosal tissue. A "tunnel" is then created in the submucosal layer down to the stomach, exposing the muscle fibers. At the end of this tunnel, the muscle layer is then cut, significantly improving food and drink entry to the stomach from the esophagus. Patients can swallow normally in as soon as 24-48 hours.
- G-POEM. G-POEM is a POEM procedure performed in the stomach to treat gastroparesis, in which the stomach does not empty effectively. The muscle bundle that is cut is the pylorus, located at the opening of the stomach into the small intestine.
Photodynamic therapy (PDT)
PDT is used to open up esophageal or biliary blockages or treat small, shallow tumors in people who cannot have open surgery. PDT cannot be used for large or deep tumors. During PDT, a drug called a "photosensitizer" is given intravenously (by vein) and absorbed only by cancer cells over a few days. Using an endoscope, the surgeon exposes the lesion to a certain wavelength of light. This triggers an active form of oxygen to be produced, which directly kills cancer cells. It also indirectly damages the tumor's blood vessels, further destroying cancer and limiting damage to surrounding healthy tissue. The endoscopist may also place a stent in the esophagus to open up a blockage and make swallowing more comfortable.
Probe-based confocal laser endomicroscopy (PCLE)
PCLE improves the early detection and treatment of cancers and precancerous conditions. A special, small microscope is used to view and analyze cells in the digestive tract to determine if they are normal or precancerous. Cancerous tissue that is found may be immediately removed through the endoscope for further examination.
Sphincterotomy
This procedure is used to open the sphincter (ring of muscle), 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 make stone removal or stent placement easier.
Stent implantation
A stent is a small tube inserted into an area of the body that is obstructed. Just as stents are routinely used to treat blockages in the heart, they may also be placed endoscopically to relieve obstructions in the digestive tract, such as those caused by tumors or inflammation. These stents resolve the obstruction, improve symptoms, and are often the first kind of treatment used before resorting to a feeding tube or surgery. Stents are placed in the digestive tract to:
- Relieve blockages in the bile and pancreatic ducts. The stent is inserted using an endoscope during endoscopic retrograde cholangiopancreatography (ERCP).
- Treat an obstruction caused by colon cancer. The stent is inserted through an endoscope inserted into the rectum.
- Relieve small bowel obstructions. The stent is inserted via an endoscope into the duodenum (the first part of the small intestine).
- Prepare for other treatments. Stents can 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).
Treatment of bile and pancreatic duct stones
Stones that form in the bile ducts or pancreatic ducts can cause severe pain and discomfort. Our interventional endoscopists used a variety of approaches to remove or destroy these stones, depending on their size and location:
- Choledochoscopy. Doctors use this "scope within a scope" to directly visualize the common bile duct. Small stones can be removed or destroyed using laser therapy or electrohydraulic lithotripsy (high-energy sound waves that break up stones).
- Pancreatoscopy. A small camera is placed inside the pancreatic duct to assess lesions, perform biopsies, and treat stones.