The Pancreatic and Interventional Endoscopy Services at Cedars-Sinai specializes in diagnosing and treating the full spectrum of diseases of the pancreas and bile ducts.
In the past few years, great strides have been made in diagnostic and therapeutic tools. Today, they are more accurate and less invasive than traditional procedures. Below is a brief description of some of these medical breakthroughs.
About Endoscopy and Endoscopes
Endoscopy refers to the process of looking inside a hollow organ with an endoscope. An endoscope is a flexible tube with a light and an optical system. It may be able to project images onto a monitor or computer screen.
There are several types of endoscopes. Some have instruments to take tissue or fluid samples for laboratory analysis. Although most are used for diagnosing illnesses, they may also be used to "stage" cancer and do what is known generally as interventional radiology. Interventional radiology uses imaging technology to treat a wide range of conditions less invasively than traditional surgery.
As endoscopy has evolved to be used therapeutically, it has had a major impact on gastroenterology. Many of these procedures are non-invasive, or require only small incisions. This often results in faster recoveries and shorter hospital stays. Just recently the Food and Drug Administration approved endoscopic suturing (sewing tissue together) and a radio frequency treatment for gastroesophageal reflux disease.
Endoscopic Ultrasound (EUS)
This is one of the most promising new tests for pancreatic disorders. An ultrasound is an image created with sound waves. It provides high resolution images of the pancreas and gastrointestinal tract. An EUS probe can show the pancreas in much greater detail than any other non-surgical diagnostic test. It can also show early phases of fibrosis, developing gallstones and changes in the pancreatic or biliary duct system. What's more, EUS can identify pancreatic tumors and metastatic cancer in the liver and surrounding areas.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
This procedure uses a special endoscope to diagnose the cause of jaundice, find and remove blocks in the gallbladder and bile ducts and diagnose and reach pancreatic tumors. After the patient is injected with a dye, the doctor inserts the endoscope through the mouth or a small incision. Once inside, the doctor can make a diagnosis, insert surgical instruments to remove a gallstone, widen or support a bile duct with a stent or take a sample of tissue or fluid for laboratory analysis. ERCP is more accurate in diagnosing pancreatic cancer than CT scans. It's also highly accurate at diagnosing a rare disorder known as choledochocele, whose symptoms include repeated attacks of acute pancreatitis, biliary colic and jaundice.
This is an ERCP procedure using a second scope to get a better view of and access to the biliary ducts for diagnosing and treating biliary colic and acute cholecystitis (a gallbladder infection) and to check for gallstone obstruction. Biliary colic often leads to acute cholecystitis. These patients often have their gallbladders removed.
Endoscopic Pancreatic Therapy
Over the past decade, endoscopic therapy of acute and chronic pancreatitis has increased steadily. Most often used to relieve pain and improve how pancreatic ducts drain, endoscopic therapy has grown to include the drainage of pseudocysts and been used in patients with severe biliary pancreatitis, pancreatic duct disruptions, strictures and obstructive calculi (stones). Pancreatitis patients who have small ducts often have dysfunction of sphincter of Oddi (the opening between the common bile duct and the duodenum). For these patients, an endoscopic sphincterotomy (cutting of the sphincter muscle) with temporary stenting is proving to be effective.
Also called an endoscopic mucosal resection, this procedure removes lesions or superficial tumors from the moist tissue layer (mucosa) of the gastrointestinal tract using an endoscope.
Intracorporeal Electrohydraulic Lithotripsy (EHL)
Gallstones that are large or difficult to remove through the bile duct can be broken into smaller pieces and then removed. There are several ways to do this. The first is intracorporeal electrohydraulic lithotripsy. In this procedure, a sudden, crushing force is delivered using a catheter wire that is placed up against the stone.
Another method is mechanical lithotripsy in which the stone crushed and collected by a heavy stainless steel basket and then removed. The third way is extracorporeal shock wave lithotripsy (ESWL), which is commonly used to crush kidney stones by placing a machine against the body and delivering a shock wave to crush the stone inside the body.
Pancreatic and Biliary Manometry
A manometer measures pressure in a certain area, in this case on the sphincter of Oddi. Manometry has for years been the technique of choice for evaluating dysfunction of the Oddi sphincter in patients with recurring acute pancreatitis. When combined with ERCP, manometry is the only way to diagnose an unusual condition known as papillary stenosis, or a very tight pancreatic duct opening.
An enteroscope lets the doctor see into the small intestine. Known as "push" enteroscopy, this was thought to have little application, since the small bowel is at low risk for disease. But in recent years it has proven to be an excellent tool for determining the cause of gastrointestinal bleeding and its treatment.
Intestinal and Biliary Stenting
A stent is an expandable device that holds tissue in place, keeps a vessel open or provides support to a weakened area. In heart patients, stents are used to keep clogged arteries open. Intestinal and biliary stents are used to keep pancreatic and biliary ducts open, particularly in cases of cancer-induced jaundice. The most popular type of biliary stent is straight or slightly curved with side flaps at each end to reduce the chance of its moving. Stents also have the potential to relieve the discomfort of malignant gastrointestinal stenosis (narrowings).