An endoscope is a long fiber optic tube with a light source at its tip that can be passed through the mouth into the gastrointestinal tract. The tip of the endoscope has a small video chip that transmits images of the gastrointestinal tract to a television monitor so that the gastroenterologist can visualize the inside of the gastrointestinal tract.
During interventional endoscopy the gastroenterologist manipulates the gastrointestinal tract by instruments that are introduced through the endoscope. For example in a patient with blockage of the bile duct the gastroenterologist inserts a small tube called a stent into the bile duct to relieve the obstruction.
A number of interventional endoscopic procedures are now available for complicated pancreatic and biliary disease. A close collaboration between the interventional gastroenterologist and a pancreatic and biliary surgeon is important to provide the optimal care to the patient. A multidisciplinary team of physicians led by an experienced pancreatic and biliary physician provides optimal care to patients with complex pancreatic and biliary diseases.
An experienced pancreatic and biliary surgeon, a gastroenterologist and medical oncologists who have a focus on pancreatic and biliary cancers often jointly evaluate patients with complex pancreatic and biliary diseases for optimal treatment planning.
The types of interventional procedures performed include the following:
Placement of bile duct stents:
Bile duct stents are needed when the patient develops jaundice due to blockage of the bile duct. The gastroenterologist passes a plastic tube from the duodenum through the blockage into the bile duct so that the blockage in the bile duct is bypassed by the stent.
Two types of stents are available: i) plastic stents and ii) metal stents. Plastic stents are placed to provide temporary relief of jaundice while the patient is being evaluated for surgical treatment for correction of the blockage in the bile duct or removal of the tumor, if a tumor is causing the blockage of the bile duct.
Metal stents are permanent stents and are placed when the patient is not a surgical candidate. Metal stents have metal hooks that anchor into the bile duct. This significantly reduces the chances of subsequent successful surgery on the bile duct. Your gastroenterologist should not insert metal stents until you have been ruled out as a surgical candidate for your disease.
Removal of stones from the bile duct:
Gallbladder stones pass into the bile duct and cause obstructive jaundice. During ERCP if the gastroenterologist finds stones in the bile then these stones can be removed during interventional endoscopy.
Endoscopic dilatation of a bile duct stricture (blockage):
This procedure is usually performed in patients who have a benign (non-cancerous) stricture of the bile duct. Benign bile duct strictures are often secondary to injury to the bile duct after a laparoscopic or open cholecystectomy.
Endoscopic treatment is less effective than surgical treatment for bile duct strictures, however, for very short strictures this treatment can avoid a surgical procedure. If the strictures do not respond to endoscopic dilatation after several attempts then surgical treatment may be indicated.
Pancreatic duct stents :
Pancreatic duct stents are often placed in patients who have chronic pancreatitis or a condition called pancreatic divisum. The use of these stents is controversial and the results are variable. Multiple pancreatic duct stents placed over a long period of time or stents that are left in the pancreatic duct for prolong periods of time can by themselves cause chronic pancreatitis in some patients.
Pancreatic duct stents should be placed only after careful consideration of other treatment options that are available for treatment of chronic pancreatitis.
Drainage of pancreatic pseudocyst:
Pancreatic pseudocyst is a collection of fluid that is found around the pancreas after a patient develops acute or chronic pancreatitis. Pancreatic pseudocyst is a pool of pancreatic juice that has leaked from an injured pancreatic duct. Pseudocysts form when the normal healing process seals of the pancreatic juice collections around the pancreas to form localized fluid collections.
Pseudocysts are treated by draining the cyst fluid into a loop of intestine or the stomach. Endoscopic treatment is one of the options that are available for treating pseudocysts. During endoscopic treatment a stent (a small tube) is placed between the stomach or the duodenum and the cyst so that the cyst drains into the gastrointestinal tract. An alternate method is to pass a small catheter through the pancreatic duct and into the cyst if the cyst is communicating with the pancreatic duct.
Careful selection of patients is very important for treatment of pancreatic pseudocyst with endoscopic techniques. While this technique can lead to cure of the pseudocyst in some patients; severe infective complications that require complicated surgical procedures by introducing bacteria into the cyst is a significant risk of this treatment. Endoscopic procedures may also aggravate the situation by causing pancreatitis.