A 70 year old male diabetic patient presented with severe jaundice for last 15 days with intractable pruritus, anorexia, cholangitic symptoms and significant weight loss.  Patient’s total bilirubin was 12 mg% and Total leukocyte count was 15000/cmm.  Endoscopic ultrasound showed a large hypoechoic mass at the porta leading to IHBR dilatation.  EUS guided FNA was performed from the mass and sent for cytological examination, which was suggestive of adenocarcinoma. Then the patient was subjected to ERCP and air cholangiogram revealed independent block of right and left hepatic ductal system with stricture at CHD leading to Bismuth Type IIIb stricture. Brushing was taken from the stricture for cytology to compare it with EUS-FNA results. Then stricture dilatation was performed and  two self expandable uncovered metallic stents (“Y” Stents) were deployed in the right and left ductal system across the stricture and free flow of dark bile with pus streaks were seen. On follow up biochemical evaluation after 3 days the sr.bilirubin level had come down to 3 mg% and patient had significant relief in symptoms.  Considering the advanced age of patient and stage of the disease, patient was referred for chemotherapy.

Expert Comments:

Biliary drainage via the endoscopic route offers the advantages of physiologic bile drainage and has been proved to be more non-invasive and comfortable for patients than that via the percutaneous route. Y-shaped endoscopic bilateral stenting using a Y-stent appears to be a feasible and effective method with high technical success and low stent-related complications for palliation of unresectable malignant hilar biliary obstruction. Since the advent of such stents that includes large cell design stents, endoscopic palliation of Hilar blocks upto Bismuth type IIIb are regularly carried out at Endoscopy Asia with good predictable outcomes and this approach obviates the need for PTC drainage.

Take home Message:

Variants of Biliary Metal Stent designs continue to be introduced with improvements in ease of placement and stent patency and provide desired outcomes. However, one should exercise caution when dealing with Hilar blocks as suboptimal drainage of obstructed ductal systems can lead to fatal cholangitis. Furthermore, these procedures should be performed by very experienced endoscopists and careful patient selection on the basis of patient symptoms and MRCP is crucial for consistent results.

EUS Showing stricturous growth in Proximal CBD

EUS Showing stricturous growth in Proximal CBD

EUS guided FNA from the Porta Node

EUS guided FNA from the Porta Node

 

 

 

 

 

 

 

 

 

 

Air Cholangiogram showing Bismuth Type III stricture with independent block in the right and left hepatic ductal system

Air Cholangiogram showing Bismuth Type III stricture with independent block in the right and left hepatic ductal system

Fluoroscopy showing “ Y” stent in situ

Fluoroscopy showing “ Y” stent in situ

 

 

 

 

 

 

 

 

 

 

 

Duodenoscopy confirming the optimal stent placement

Duodenoscopy confirming the optimal stent placement

A 76 year old female presented with severe jaundice and itching associated with intractable vomiting for last 10 days.  Patient had been diagnosed by us as a case of adenocarcioma of pancreatic head and uncinate process on Endoscopic ultrasound (EUS)  guided FNAC  and EUS evaluation suggesting the tumor to be invading into the duodenum as well as the SMV-portal vein confluence, rendering it inoperable, three months back.  A repeat endoscopic evaluation on this visit revealed the tumor to be invading the D1-D2 junction, causing gastric outlet obstruction. Balloon dilatation of the stricturous duodenal segment was performed so as to rail road the duodenoscope over the guidewire into the second part of duodenum. Endoscopic retrograde cholangiogram (ERC) revealed bile duct obstruction in the intra-pancreatic part of CBD with dilated upper CBD. In view of these findings and inoperable nature of the disease, a self expandable 8 cm uncovered metallic billiary stent and a self expandable uncovered 14cm pyloro-duodenal metallic stent was placed as a means of palliation. Patient was completely relieved of the symptoms of bile duct obstruction as well as gastric outlet obstruction in three days.

Expert Comments:

Almost 85% of patients of pancreatic cancer are deemed unsuitable candidates for curative resection at the time of diagnosis. Obstructive jaundice occurs in 70-80% of such patients and approximately 5% patients develop duodenal obstruction at some point before their death. Patients who require relief of bileduct obstruction and are not candidates for possible curative resection, it has been a standard of care to perform endoscopic stent placement. Meta-analyses comparing enteral stent placement with gastro-jejunostomy have confirmed the high technical and clinical success rates of stent placement and indicated favorable outcomes with pyloro duodenal stenting. Endoscopy provides Detection, Diagnosis, Staging with EUS & FNA followed by palliation through ERCP with Metal Biliary Stenting and Pyloro-Duodenal Stenting.

Take Home Message:

In view of more patients presenting in poor nutritional and general health status, intolerability to surgical stress and relatively short expected survival, self expandable metallic stents provide an attractive alternative to palliative surgical intervention. However, careful evaluation of the patient and procedural expertise are required for predictable post-procedural outcome. At Endoscopy Asia this protocol of EUS-ERCP-Endotherapy for such advanced inoperable pancreatic cancer palliation has been practiced for over 13 years. We feel that Surgical Palliation of such a problem can be obviated in almost all the cases leading to either cholestatic or gastric outlet obstructive symptoms.

Mass in the Head of Pancreas encasing SMV-Portal Vein confluence

Mass in the Head of Pancreas encasing SMV-Portal Vein confluence

EUS guided FNA of the Pancreatic Head Mass

EUS guided FNA of the Pancreatic Head Mass

 

 

 

 

 

 

 

 

 

 

Cholangiogram showing Obstruction at Lower  end of CBD with Proximal CBD Dilatation

Cholangiogram showing Obstruction at Lower end of CBD with Proximal CBD Dilatation

Self expandable biliary metallic stent in-situ

Self expandable biliary metallic stent in-situ

 

 

 

 

 

 

 

 

 

 

Guide wire in-situ across  the Stricturous duodenal segment

Guide wire in-situ across the Stricturous duodenal segment

Self expandable Pyloro-Duodenal Metallic stent in-situ

Self expandable Pyloro-Duodenal Metallic stent in-situ

A 32 yr old female was referred to us for EUS sos ERCP for suspected lower CBD stricture and upstream CBD dilatation in a setting of gall bladder stones with mild LFT abnormality. Endosonographic examination revealed small 9mm papillomatous lesion in the ampulla extending into the prepapillary portion of CBD measuring 12mm x 8 mm. Gall Bladder contained multiple stones. MPD and Pancreas appeared normal. No evidence of nodes or free fluid. Patient was taken up for ampullectomy, endoscopic resection of the papillomatous lesion followed by biliary sphincterotomy. After ampullectomy and endoscopic resection a 3 fr stent was placed in the MPD to prevent post procedural pancreatitis and a 7 fr stent was placed in CBD to ensure effective ductal decompression. Histopathological examination of the resected tumor revealed a villous adenoma of ampulla of vater.

Expert Comments: Surgical management of ampullary or intra-ampullary tumor may carry risk of significant morbidity, including anastomotic dehiscence, fistulae & mortality. Endoscopic approaches for the evaluation and treatment of ampullary adenomas now represent a viable alternative to surgical therapy. EUS can accurately predict depth of Invasion of benign ampullary and duodenal adenomas with an acceptable sensitivity, specificity and a negative predictive value, along with locoregional nodal status. These patients can safely undergo endoscopic or local resection with an acceptable local control rate sparing the need for more extensive surgical resections.

Take Home Message: USG abdomen, CT SCAN and even an MRCP may miss distal CBD lesions or even misinterpret it. EUS is perhaps the most accurate investigation for imaging the lower CBD and that can influence the treatment design, as we have seen in this case, that a young female was treated with endoscopic resection. A close clinical and biochemical follow up is advocated in such cases, so that we do not miss any aggressive neoplastic process underlying. We also feel that with the advent of peroral cholangioscopes, lesions such as these would be more effectively managed in coming years as we grow in experience. However, I would like to reiterate that the fundamental key to such an intervention is a very accurate EUS assessment.

EUS picture showing dilated CBD

EUS picture showing dilated CBD

EUS picture showing intra-ampullary tumor

EUS picture showing intra-ampullary tumor

 

 

 

 

 

 

 

 

 

 

Cholangiogram confirming the EUS findings

Cholangiogram confirming the EUS findings

Endoscopic removal of tumor

Endoscopic removal of tumor

 

 

 

 

 

 

 

 

 

 

Picture showing the tumor after complete resection

Picture showing the tumor after complete resection

Post stent removal followup EUS showed completely clear prepapillary CBD

Post stent removal followup EUS showed completely clear prepapillary CBD

A 53 yr old female was referred to us for OGD Scopy to evaluate exact etiology of patient’s symptoms of drop in haemoglobin. Previous endoscopy done in elsewhere showed a suspicious lesion in the duodenum which could be the potential site of bleeding. However, no active treatment was given at that time and therefore a repeat endoscopy was considered. OGD Scopy revealed normal esophagus and cardia. Few metaplastic lesions were seen in the fundus which were very much appreciated on NBI at the junction of D1 and D2 a villous umbilicated lesion was seen. On NBI the pit pattern was suggestive of neoplastic activity without any bleeding stigmata. On EUS examination, the duodenal lesion appeared to be limited to the mucosa and muscularis mucosa thus feasible for EMR and therefore endoscopic mucosal resection (EMR) was then performed with free hand technique. Histopathological report was suggestive of Follicular Lymphoma. Patient was then asked to have an opinion of a medical oncologist.

Expert Opinion: Follicular Lymphoma of duodenum is a low-grade lymphoma that usually develops very slowly. Many studies recommend for a watch and wait strategy for low grade diseases without extensive nodal spread.

Take Home Message: Procedures such as these should be ideally performed in centres where integrated facility of high resolution endoscopy, EUS and safe EMR techniques are routinely performed.

Endoscopic picture showing duodenal lesion

Endoscopic picture showing duodenal lesion

EUS picture showing submucosal invasion of the lesion

EUS picture showing submucosal invasion of the lesion

 

 

 

 

 

 

 

 

 

EMR of the duodenal lesion

EMR of the duodenal lesion

The resected Duodenal Polyp

The resected Duodenal Polyp

A 23 yrs female patient was referred to us for the favor of EUS (Endoscopic Ultrasound) evaluation of a suspected inoperable mass in the pancreatic head on CT scan and MRI of abdomen. Patient was seen previously by a leading senior consultant, who saw the reports and suggested that nothing can be done as the mass has encased the portal vein and hepatic artery and she should be left alone. After that they decided to visit our unit and we felt that an EUS is mandatory to get more information. EUS revealed a large hypoechoic mass measuring 4.0 cms x 5.0 cms near the pancreatic head and it appeared encompassing major blood vessels, however, the mass did not appear to be arising from pancreatic head, but looked more like a large conglomerate of nodes leading to an impression of pancreatic head mass. EUS guided FNA was then performed which showed purulent material that was sent for cytological examination as well as AFB culture and sensitivity. After that ERC was performed which showed narrowing of the mid CBD and therefore, after biliary sphincterotomy a 10 fr stent was placed to ensure effective ductal decompression. The cytological examination revealed tubercular lymphadenitis posed as a mass near the head of pancreas. Patient was therefore given anti tubercular treatment and sent back home.

Expert Comments

As we have seen in this case, where on the basis of CT scan and MRI, the patient who was deemed inoperable with a pancreatic head mass, had actually a large nodal mass which gave an impression of pancreatic head tumor. EUS and guided FNA provided the diagnosis of tubercular nodes leading to obstructive jaundice which was addressed at the same time with ERCP and biliary stenting. Thus, patient had a completely different diagnosis and treatment strategy due to EUS-ERCP Interface protocol which we have pioneered not only in India but perhaps this part of the world.

Take Home Message

Whenever you see a young patient with suspected mass in the pancreas, you will have to think of such pathology as mentioned in the above case. It our experience that ERCP alone would not have given the diagnosis and therefore it will be mandatory for all leading Endoscopy & Gastroenterology Institutes to practice the protocol of EUS-ERCP Interface.

A large hypoechoic conglomerate of nodes seen leading to CBD narrowing and encasing the portal vein

A large hypoechoic conglomerate of nodes seen leading to CBD narrowing and encasing the portal vein

The nodal mass appeared necrotic and CBD appeared pinched

The nodal mass appeared necrotic and CBD appeared pinched

 

 

 

 

 

 

 

 

 

 

EUS guided FNA performed from the nodal mass which appeared like a tumor

EUS guided FNA performed from the nodal mass which appeared like a tumor

After selective cannulation of CBD, biliary sphincterotomy was performed

After selective cannulation of CBD, biliary sphincterotomy was performed

 

 

 

 

 

 

 

 

 

 

Cholangiogram revealed mid CBD narrowing due to nodal mass compression

Cholangiogram revealed mid CBD narrowing due to nodal mass compression

A 10 fr biliary stent placed which showed free flow of bile

A 10 fr biliary stent placed which showed free flow of bile

A 67 yrs male diabetic patient was referred to us for the favor of EUS evaluation for a suspected pancreatic tumor on CT Scan, which showed a 4 cms lesion in the genu and body of pancreas. Patient did not have any jaundice and has undergone PET CT Scan which showed the mass in the pancreas without any obvious distant metastasis and therefore was scheduled for surgery by a leading oncosurgeon.

However, patient was reluctant getting surgery done without tissue diagnosis and therefore the family physician referred this patient for an EUS sos guided FNA. EUS revealed an irregular hypoechoic mass in the genu of pancreas extending into the body of pancreas measuring 4.5 cms x 3.5 cms. The mass appeared to adherent to Splenic vein / Portal  vein confluence with few hypoechoic peritumorous nodes. There was minimal free fluid was seen in the perihepatic space ( 1-2 ml) and while examining the left lobe of liver on EUS we saw three subcentimeter hypoechoic lesions in the left lobe of liver which were completely missed on CT Scan as well as on PET CT Scan.

In view of these findings, EUS guided FNA was then performed from the left lobe liver lesion and also from the primary tumor in the pancreas. The cytology report showed liver FNA to be metastatic adenocarcinoma and the pancreatic lesion also showed poorly differentiated adenocarcinoma. Thus, after these results the surgery was cancelled and patient was given an option of neoadjuvant therapy and symptomatic treatment.

Expert Comments

As we have seen in this case that on the basis of CT Scan and PET CT Scan the patient was considered resectable and was scheduled for surgery. However, due to EUS we were able to get tissue diagnosis not only from the primary mass but also from detected subcentimeter liver metastasis that were completely missed on CT Scan as well as PET CT Scan. This protocol allowed us to change the management strategy in this patient.

Take Home Message

Our experience of over 17,000 EUS procedures have taught us one lesson and that is whenever a tumor in pancreas seen resectable or unresectable on CT Scan and PET CT Scan it is worth getting an EUS guided tissue diagnosis and accurate staging before a definitive surgery or neoadjuvant therapy. As we know that subcentimeter small liver metastasis and minimal ascites are usually difficult to detect on all conventional CT scans and PET CT scans at present. I am sure these are evolving protocols and in coming years when more efficient EUS centres will start in India, we will see this staging protocol implemented in routine practice.

EUS showed an irregular hypoechoic mass in the pancreatic body

EUS showed an irregular hypoechoic mass in the pancreatic body

EUS Guided FNA of the pancreatic mass performed

EUS Guided FNA of the pancreatic mass performed

 

 

 

 

 

 

 

 

 

 

A small 6 mm hypoechoic lesion seen in the left lobe of liver

A small 6 mm hypoechoic lesion seen in the left lobe of liver

EUS guided FNA of the left lobe liver 6 mm lesion performed, tip of the needle seen transgastric into the lesion on EUS

EUS guided FNA of the left lobe liver 6 mm lesion performed, tip of the needle seen transgastric into the lesion on EUS

A 30 yrs male was referred to us for the favor of endoscopic evaluation and management of suspected pancreatic ascites on abdominal tapping following a vehicular accident. Patient has undergone repeated tapping of fluid which was rich in Amylase and was therefore sent to us for treatment.

ERCP was considered and after selective cannulation of Pancreatic duct, the pancreatogram showed free spillage of contrast from the tail of pancreas in a near normal sized main pancreatic duct. Pancreatic sphincterotomy was then performed and a 5 fr stent was placed right upto the point of leakage of the duct. Free flow of pancreatic juice was seen from the stent. Patient was followed up and had complete resolution of ascites within 72 hrs of placement of the pancreatic stent.

Expert comments

As we have seen here following a vehicular accident, if free fluid is present in the peritoneal cavity and on aspiration if it is not frank blood but watery fluid or even slightly blood stained serous fluid, this should be sent for amylase estimation. As correctly diagnosed pancreatic ascites in this case, we were able to manage this with ERCP, pancreatic sphincterotomy and pancreatic stenting. Even though the main pancreatic duct is not dilated, careful intervention can save a major complication or surgical intervention. The placed pancreatic stent is usually removed after 6 weeks which showed normal pancreatogram without leak.

Take home message

Pancreatic diseases can be effectively diagnosed and managed endoscopically as seen in this case. There is a strange perception in the medical fraternity that patients with recurrent acute pancreatitis or early chronic pancreatitis should be left alone and treated with medicines and nothing can be done. I would appeal to all colleagues, please consider Endoscopic Ultrasound evaluation for patients suspected to have pancreatic disease and followed by Endotherapy of recurrent or chronic pancreatitis if required, which can effectively stop or reduce the frequency of recurrent attacks of pancreatitis in most cases.

Normal Ampulla of Vater

Normal Ampulla of Vater

Selective cannulation of MPD (Main Pancreatic Duct)

Selective cannulation of MPD (Main Pancreatic Duct)

 

 

 

 

 

 

 

 

 

Pancreatogram showed free spillage of contrast in the tail of pancreas from an undilated MPD

Pancreatogram showed free spillage of contrast in the tail of pancreas from an undilated MPD

Pancreatic sphincterotomy performed

Pancreatic sphincterotomy performed

 

 

 

 

 

 

 

 

 

 

A 5 french stent was placed in the pancreatic ductupto the tail at the site of leakage

A 5 french stent was placed in the pancreatic
ductupto the tail at the site of leakage

Fluoroscopy showed 5fr stent right upto the tail of pancreas in the MPD

Fluoroscopy showed 5fr stent right upto
the tail of pancreas in the MPD

A 77 years old male patient was referred to us for the favour of EUS sos ERCP for CBD stricture suspected on other imaging studies (Ultrasonography and CT scan of abdomen) which showed dilated CHD and IHBR with contracted gall bladder. Blood investigation revealed a normal LFT. Patient presented with severe epigastric pain. EUS revealed two large stones in CBD measuring 2 x 1.5 cms with wide cystic duct. One of the stones appeared like Mirrizi syndrome. In view of these findings, ERC was performed and cholangiogram confirmed the EUS findings of choledocholithiasis. In view of these findings, biliary sphincterotomy was performed followed by balloon sphincteroplasty with 15 mm CRE balloon at & ATM pressure and both the stones were extracted using balloon catheter and dormia basket with great difficulty, for complete ductal clearance. A 7 Fr double pigtail stent was then placed because of the aggressive endotherapy employed. Patient was again called after 6 weeks for stent removal.

Hence, endoscopic treatment for very large CBD stone is a safe and effective in expert hands and does not require surgical intervention or more expensive lithotripsy devices.

Expert Comments:

As we have seen in this case large CBD stones measuring upto 2 centimeters can be successfully extracted without lithotripsy with a modified technique with balloon sphincteroplasty. We have been practicing balloon sphincteroplasty for over 8 years in India with consistent results without any major complications. Selection of size of balloon in relation to the size of stone and lower CBD is critical for the outcomes of the procedure. Our experience is not to dilate beyond 15 – 16 mm with a balloon for safety. As a routine, we try and retrieve the extracted stone beyond 1.5 cms with dormia basket from the duodenum as it may lead to gall stone ileus.

Take Home Message:

Large CBD stones upto 2cms does not always require mechanical / laser lithotripsy. Small subset of patients (approximately 5%) of total patients with large CBD stones (>1.5 cms) may require lithotripsy procedures. Careful selection of patient, accessories and correct technique ensures predictable outcomes.

EUS showed  large 2.0 cms stone in the lower CBD

EUS showed large 2.0 cms stone in the lower CBD

After Biliary sphincterotomy, Balloon sphincteroplasty  was then performed with a 15 mm balloon

After Biliary sphincterotomy, Balloon sphincteroplasty
was then performed with a 15 mm balloon

 

 

 

 

 

 

 

 

 

 

Cholangiogram showed large CBD stones

Cholangiogram showed large CBD stones

Stone extracted using stone extraction balloon catheter

Stone extracted using stone extraction balloon catheter

 

 

 

 

 

 

 

 

 

 

7 Fr double pigtail catheter placed

7 Fr double pigtail catheter placed

Stone retrieval from duodenum using dormia basket

Stone retrieval from duodenum using dormia basket