A 75 yrs male was referred to us for the favor of evaluation of exact etiology of obstructive jaundice. The total bilirubin was 23mg% and patient had few episodes of fever with chill recently. Hence EUS was considered to evaluate the exact etiology of obstructive jaundice. EUS revealed a large mass in the pancreatic head which appeared malignant and was seen invading the duodenal wall, lower CBD, MPD, SMA & SMV. Further more, large hypoechoic nodes were seen in the celiac axis region. In view of these findings EUS guided FNA was performed from the pancreatic head mass and the celiac axis nodes. Subsequently due to recurrent cholangitis ERCP was performed and after biliary sphincterotomy a self expandable. metal stent was placed into the CBD which showed free flow infected bile. The procedures were performed on OPD basis and patient was sent home the same evening.

 

Expert Comments:

As we can see in this case due to very advanced nature of pancreatic tumor which eventually turned out tobe a poorly differentiated adenocarcinoma on EUS guided FNA of the mass and nodes, a single step detection, diagnosis, staging and palliation of malignant obstructive jaundice was performed in one sedation on an OPD basis. Several studies have shown that whenever there is a patient of obstructive jaundice of uncertain diagnosis, EUS will provide accurate diagnosis in most cases. It is a standard protocol at Endoscopy Asia that if a patient has obstructive jaundice and if the diagnosis is not clear on previous other imaging studies,  then patient will be subjected to EUS sos EUS guided FNA if there is a mass lesion followed by ERCP and ductal clearance if stones are seen or stenting if a malignant lesion is encountered. Studies have shown that most patient who are diagnosed with Pancreatic adenocarcinoma who present with obstructive jaundice are advanced in their presentation and hence Surgery should be considered only if there is a chance of cure and R0 resection without nodal involvement, and in most centres across the world role of palliative surgery is now diminishing. Since the advent of EUS / FNA and Metal Biliary stenting / Duodenal stenting, endoscopic palliation is now a preferred approach. If patient has intractable pain due to advanced pancreatic cancer then in the same sedation we can also offer EUS guided Coeliac Plexus Neurolysis (EUS-CPN) thus completing the entire spectrum of palliative care.

This approach of EUS sos ERCP provides accurate diagnosis and optimal management of obstructive jaundice in most patient without any additional investigations or interventions. This has been our practice for over 13 years since I pioneered Pancreato-biliary EUS in India and we hope that more such centres across the country will incorporate such a protocol in years to come.

EUS showed a large hypoechoic mass In the pancreatic head leading to obstructive jaundice

EUS showed a large hypoechoic mass In the pancreatic head leading to obstructive jaundice

Large hypoechoic mass in the pancreatic head invading the SMA and SMV

Large hypoechoic mass in the pancreatic
head invading the SMA and SMV

 

 

 

 

 

 

 

 

Hypoechoic nodes were seen in the celiac axis region- suggestive of distant nodal metastasis

Hypoechoic nodes were seen in the celiac axis region- suggestive of distant nodal metastasis.

EUS guided FNA of the pancreatic head mass performed. Needle was passed transduodenally under EUS guidance.

EUS guided FNA of the pancreatic head mass performed. Needle was passed transduodenally under EUS guidance.

 

 

 

 

 

 

 

 

ERCP showed dilated upper CBD with a stricture In the region of pancreatic head

ERCP showed dilated upper CBD with a stricture In the region of pancreatic head

ERCP and placement of Self expandable  Metal biliary stent

ERCP and placement of Self expandable
Metal biliary stent

A 53yrs Female, was referred to us with a diagnosis of poorly differentiated Squamous Carcinoma of Lower 1/3rd Esophagus for Staging sos Palliation of absolute Dysphagia with severe Comorbidities.

Endoscopic & EUS staging showed T3N2Mx. Since patient was reluctant for neoadjuvant treatment, a Self Expandable Covered Antireflux Metal Stent was then placed across the stricture after Balloon Dilatation under Endoscopic & Fluoroscopic control.

Patient started taking oral feeds few hours after stent placement and was sent home the same evening uneventfully.

 

Expert Comments :

As we can see in this case, patient with absolute dysphagia due to advanced lower 1/3rd esophageal malignancy with extensive nodal metastasis, who is a poor surgical risk and who does not want neoadjuvant treatment. We feel that this approach of Endoscopic staging and palliation with a metallic stent placement was ideal in such a patient. The procedure was done on a daycare  basis and patient was sent home the same day.

A large ulceroproliferative stemotic lesion at 35cms from the incisors teeth

A large ulceroproliferative stemotic lesion at 35cms from the incisors teeth

Balloon dilatation was performed

Balloon dilatation was performed

 

 

 

 

 

 

 

 

The lesion seems to have invaded the cardia on retroflexion

The lesion seems to have invaded the cardia on retroflexion

EUS staging showed T3N2Mx

EUS staging showed T3N2Mx

 

 

 

 

 

 

 

 

A self expandable covered antireflux metal stent was deployed across the stricture

A self expandable covered antireflux metal stent was deployed across the stricture

Optimal stent deployment was confirmed on constrast study on fluroscopy

Optimal stent deployment was confirmed on constrast study on fluroscopy

A 48yrs/ F was referred to us for the favor of colonoscopy to evaluate the exact etiology of bleeding per rectum off and on for last 6 months leading to drop in Hb. Patient was treated conservatively for colitis and piles by a family physician. However, patient continued to have symptoms despite several months of treatment and hence went to see a Surgeon who asked for a colonoscopic evaluation.

Ileo-colonoscopic evaluation revealed a large 4 cms bilobed polyp with a thick stalk at the recto-sigmoid junction. Rest of the colon upto the caecum and also the last 15 cms of terminal ileum was normal. Polypectomy was then performed with a snare and cautery after injection of diluted saline adrenaline into the stalk. Complete resection of the polyp was achieved and was sent for HPE, which revealed tubulovillous adenoma without dysplasia. Patient was sent home the same evening.

Expert comments

Patient above the age of 45 yrs with h/o bleeding per rectum should be investigated in detail and empirical treatment without a definitive diagnosis should be avoided. In this case patient suffered for almost 6 months before getting the a definitive diagnosis and effective endoscopic treatment in the same sedation and was cured of her symptoms. Pedunculated or even flat sessile colonic lesions can be successfully resected with endoscopic techniques such as polypectomy as in this case or we can employ more sophisticated tools that can perform EMR ( Endosocpic Mucosal Resection ) or ESD ( Endoscopic Submucosal Dissection).

It is our policy at Endoscopy Asia to inspect 10-15 cms of terminal ileum in all patients referred to us for Colonoscopy and more so if we are looking for a lesion that could bleed. It is also important to perform these procedures under one sedation at the pilot endoscopy, both the diagnostic and therapeutic aspects when we deal with bleeding per rectum in an infrastructure which is equipped enough with all the methods of endoscopic haemostasis.

Large bilobed polyp with thick stalk seen in Recto-sigmoid region.

Large bilobed polyp with thick stalk seen in Recto-sigmoid region.

Diluted saline adrenaline injected in the stalk

Diluted saline adrenaline injected in the stalk

 

 

 

 

 

 

 

 

The stalk strangulated with a polypectomy Snare

The stalk strangulated with a polypectomy
Snare

No evidence of bleeding from the resected site

No evidence of bleeding from the resected site

 

 

 

 

 

 

 

 

Polyp retrieved with a Roth net.

Polyp retrieved with a Roth net.

Bilobed resected polyp was sent for histopathological examination

Bilobed resected polyp was sent for histopathological examination

A 36 yrs/ Male referred to us for the favor of EUS ( Endoscopic Ultrasound) sos guided drainage of Pancreatic pseudocyst secondary to an episode of severe acute pancreatitis ( alcohol related) about 11 months back. The size of pseudocyst was around 11 cms x 10 cms and there was no regression of size in the last 11 months and patient complained of intermittent pain and vomiting and hence EUS was considered.

EUS showed a large pseudocyst with some compression on stomach without any abnormal vessels or pseudoaneurysm. EUS guided cystogastrostomy was then performed with a therapeutic EUS scope. After placement of double pigtail stent the pseudocyst regressed immediately and patient was observed overnight and sent home the next day. On follow up patient is symptomatic and stent has been removed, so far in 23 months of follow up there is no recurrence.

 

Expert comments:

It is well known that after an episode of acute pancreatitis some patient may develop pseudocyst of pancreas. Almost 2/3rd of them resolve spontaneously over a period of 6-8 months and about 1/3 of them may become symptomatic which requires treatment. Traditionally the treatment of Pancreatic Pseudocyst has been Surgical – either open surgery or Laparoscopic.

However, with the advent of EUS guided drainage, in our experience for last 1 decade eversince we pioneered the Interventional EUS in Mumbai and India, almost 95-97% of symptomatic Pseudocysts at Endoscopy Asia can be managed with EUS guided drainage procedure. Published studies have shown similar conclusion that most patients with Pancreatic pseudocyst either secondary to acute or chronic pancreatitis can be managed successfully with EUS guided drainage, hence the role of Surgery is there only if EUS infrastructure and expertise are not available, especially if there is a non bulging pseudocyst..

Though large bulging pseudocysts can be drained even endoscopically, whenever possible EUS guided drainage will provide a safer window of puncture across the gut wall and thereby prevent complications such as bleeding and perforation that can occur.

EUS showed large pseudocyst without debris

EUS showed large pseudocyst without debris

EUS guided transgastric puncture

EUS guided transgastric puncture

 

 

 

 

 

 

 

Puncture tract dilated with cystotome

Puncture tract dilated with cystotome

Tract further dilated with a 6 mm balloon

Tract further dilated with a 6 mm balloon

Double pigtail stent draining clear Pseudocyst fluid into the stomach

Double pigtail stent draining clear
Pseudocyst fluid into the stomach

Fluoroscopy shows double pigtail stent Placed across the stomach wall into the Pseudocyst. Echoendoscope seen.

Fluoroscopy shows double pigtail stent
Placed across the stomach wall into the Pseudocyst. Echoendoscope seen.

 

 

 

A 46 yrs male was referred to us for the favor of EUS sos ERCP in view of suspected CBD obstruction. All the imaging studies including MRCP showed a normal CBD and did not reveal any pathology that can explain mildly abnormal LFT in the setting of multiple small stones in the gall bladder seen on USG abdomen. EUS revealed normal sized CBD with an small (4.0 mm)impacted stone in the prepapillary portion of the CBD. EUS showed distended Gall bladder with multiple small stones and imaging microliths. Pancreas and MPD appeared normal on EUS. In view of these findings ERCP was considered in the same sedation after EUS. After selective cannulation of CBD cholangiogram showed normal sized CBD, a biliary sphincterotomy was then performed and the stone that was seen on EUS was extracted with a dormia basket and CBD was cleared. Patient was sent home the same evening on an OPD basis.

Expert comments:

As seen in this case when there is a LFT abnormality in the setting of gall stones and even when an MRCP is normal, one should consider EUS sos ERCP to be sure prior to laparoscopic cholecystectomy. It is our practice for over a decade now that any patient who has suspected CBD stone referred to us will be first subjected to EUS and only after a definitive diagnosis of the pathology, then an ERC will be considered only as a therapeutic invtervention in the same sedation.

For a suspected CBD stone, ERCP cannot be justified for diagnostic purpose and should be avoided when we have other more reliable and less hazardous procedures such as MRCP or EUS are available for an accurate diagnosis. At our institute it’s a policy that whenever any pathology is suspected in the lower CBD and if there is no definitive diagnosis is made on Trans-abdominal ultrasound then we would consider EUS straight away without any other imaging modalities as the diagnostic accuracy of EUS at Endoscopy Asia is in the range of 98-99%.

1. EUS showed normal CBD with multiple stones in the Gall bladder

2. A small 4.0 mm stone was seen in the prepapillary portion of CBD

3. Selective cannulation of CBD was achieved

4. Cholangiogram revealed normal sized CBD

4. Cholangiogram revealed normal sized CBD

5. Biliary sphincterotomy was performed

5. Biliary sphincterotomy was performed

 

 

6. A 4.0 mm stone seen on EUS was then extracted with dormia basket.

6. A 4.0 mm stone seen on EUS was then extracted with dormia basket.