Advanced interventional endoscopy
Section snippets
Choledocholithiasis
There is no consensus on the optimal treatment of choledocholithiasis, particularly in patients who undergo cholecystectomy. Eventually, prospective randomized trials will sort out the differences between the different therapeutic modalities.
Currently, the diagnostic standard for common bile duct (CBD) stones in the patient who has undergone gallbladder surgery is intraoperative cholangiography (IOC). Some surgeons routinely perform IOC. For those surgeons who perform selective IOC or
Indications for preoperative ERCP in the treatment of common bile duct (CBD) stones
For patients with gallstones, mild enzyme elevations, and no suggestion of malignant disease whose condition is stable, the best approach is laparoscopic cholecystectomy and IOC without ERCP. It is a single procedure, carries no pancreatitis risk, and 70% to 80% of cholangiogram results will be negative (Fig 1). . Basket extraction of distal common bile duct stone (arrow).
There are specific relative indications for preoperative ERCP. Patients with mildly abnormal liver functions and elevated
Endoscopic treatment of bile duct injuries
The early 1990s witnessed a surge in the incidence of CBD injuries during the learning curve of laparoscopic cholecystectomy. Major bile duct injuries occur in less than 0.5% of the 600,000 laparoscopic cholecystectomies performed annually in the United States.19
Classification of bile duct injuries
The treatment and outcome of biliary injuries vary considerably and are dependent on the type of injury, its location, and the time of its appearance. Injuries that involve the CBD or distal common hepatic duct are easier to repair than are more proximal injuries.20 The anatomic classification of Bismuth20 has been adopted widely for the classification of biliary tract injuries. In this classification scheme, 5 stricture types are recognized that reflect the location, with respect to the
Endoscopic treatment of malignant bile duct strictures
Malignant bile duct strictures can be of either biliary or pancreatic origin. Rarely, metastatic involvement of periportal tissue can be the cause. Approximately 28,000 new cases of pancreatic cancer occur every year in the United States, and almost all of these patients eventually die of the disease.40 Pancreatic cancer is the fourth leading cause of overall cancer deaths, despite its relatively low incidence of approximately 10 per 100,000 individuals in Western countries.41, 42 Because early
Complications of endoscopic treatment of malignant obstructive jaundice
The small sphincterotomies that are performed in conjunction with stent placement yield a complication rate much lower than the 6% to 8% that is quoted generally for endoscopic sphincterotomy in the setting of bile duct stone disease. Late complications include stent clogging by the formation of adherent bacterial biofilm or tumor ingrowth. Both can lend to cholangitis and jaundice. Tumor growth occurs in approximately 7% of patients with Wallstents.69 Rarer complications include stent
Acute pancreatitis
Pancreatitis is a common condition. Alcohol exposure, the passage of gallstones, numerous medications, and hyperlipidemia are factors that have been associated with an acute inflammatory process in the pancreas. Hereditary and idiopathic pancreatitis occur in the absence of these factors. There is a wealth of basic science literature regarding the cellular inflammatory cascade in pancreatitis, but a unifying pathophysiologic theory remains elusive.71, 72, 73
Patients with severe gallstone
Chronic pancreatitis
Chronic pancreatitis is a most difficult clinical problem for the physician and for the patient. There is a well-known association with alcohol, but the occurrence and progression years after exposure and abstinence are notorious. The exact pathophysiologic features of this disease are still ill defined. Chronic pancreatitis is most likely the result of a heterogeneous compilation of diverse, but occult, causative factors that share a chronic inflammatory effect on the pancreas as their end
Ampullary stenosis
The ampullary region is the point of exodus of the biliary and main pancreatic excretory systems. Distal outflow obstruction is usually due to an intraluminal lithiasis but can also be caused by extrinsic compression caused by periampullary tumors, choledochoceles, or inflammation. An intrinsic obstruction of the ampullary sphincter, in the absence of these lesions, may be due to scarring from previous episodes of stone passage or a failure to decrease tone at the physiologically appropriate
Ampullary tumors
This group of tumors includes adenomas, distal variants of biliary papillomatosis, ampullary hamartomas, adenomyoma, stromal tumors, inflammatory pseudotumors, heterotopias in the benign category, and carcinomas, the more common type in the malignant form. Ampullary adenoma is a rare lesion and is either a more tubular or more papillary type, with a potential of being precancerous. This tumor affects both sexes equally and is uncommon before the age of 50 years. It has also been reported to
Ampullary tumors in familial adenomatous polyposis
FAP is an autosomal dominant disease that is characterized by the development of multiple adenomas of the gastrointestinal tract. The treatment of colorectal polyps with total abdominal colectomy is more or less standardized. Periampullary and duodenal adenomas are reported to be present in up to 80% of patients in most studies from Western countries.140, 141 Next to the colon, the duodenum and the periampullary areas are the most common sites for malignancy to occur; tumors in these areas
Choledochal cysts
The cause of choledochal cysts is not fully understood. There is a definite congenital type, in addition to an acquired type, that is suggested by a delayed clinical presentation. There are 5 different anatomic variants, depending on the location of the cystic changes (Longmire/Alonso-Lej classification, types I-V). The treatment for patients with choledochal cysts is dependent on the cyst anatomy or type, age, and symptoms. All symptomatic patients are treated. Currently, resectional surgery
Primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) is a disease of unclear cause that typically affects young men and that is associated strongly with ulcerative colitis. Interestingly, the surgical treatment of ulcerative colitis has no positive effect on the course of the hepatobiliary disease, and patients with both ulcerative colitis and PSC are more likely to harbor a colonic neoplasm.158 PSC should be in the differential diagnosis of all patients with chronic cholestasis.
ERCP is the diagnostic test of
Upper gastrointestinal hemorrhage
Upper gastrointestinal hemorrhage occurs at a rate of approximately 100 cases per 100,000 individuals per year.169, 170 Morbidity and mortality rates are related to the underlying illness rather than the bleeding itself.171Mortality is related frequently to the degree of initial bleeding, rebleeding after endoscopic therapy, age of the patient,170and other comorbidities.172 After initial stabilization, endoscopic therapy has a major role in the initial diagnosis and treatment. Advances in
Variceal upper gastrointestinal hemorrhage
Acute variceal hemorrhage accounts for 10% to 30% of all cases of hemorrhage from the upper gastrointestinal tract.174 The incidence of varices in a prospective observational study with a mean follow-up period of 11 years was 4.5% in patients with newly diagnosed, compensated liver cirrhosis. The mortality rate from variceal bleeding was approximately 0.5% per year.175 Variceal bleeding is a frequent complication of portal hypertension and occurs in an estimated 40% of patients with cirrhosis.
Gastric varices
Gastric varices are more difficult to treat because they are located deeper in the submucosa than esophageal varices, which makes sclerotherapy and ligation usually ineffective. A combination of ligation of the bleeding point followed by cyanoacrylate injection was found to be effective in 1 study.199 Electrocoagulation of gastric varices was reported to have a success rate of 97% and a 2.8% mortality rate during a 10-year follow-up period.200 Endoscopic rubber band ligation of gastric varices
Nonvariceal upper gastrointestinal hemorrhage
Approximately one half of acute upper gastrointestinal hemorrhage is accounted for by peptic ulcer disease. Recent data, however, suggest that the frequency may be much lower, at 25% to 29%.206 The second most frequent cause of bleeding, according to a study from Georgetown University, was portal hypertension, which was responsible for 19% of cases overall and 31% of cases in patients under the age of 60 years.206 The decrease in the relative incidence of peptic ulcer bleeding has been
Small intestinal hemorrhage
Gastrointestinal bleeding with no identifiable endoscopic source accounts for up to 10% of patients.232 These bleeding episodes often have an origin in the small bowel. Common causes of small intestinal bleeding are shown in Table 5.233 . Common causes of small intestinal hemorrhageTumors Ulcers Arteriovenous malformations Crohn's disease Jejunal diverticula Meckel's diverticulum
In this setting, the evaluation includes a tagged red blood cell scan,234 enteroclysis (yield less than 10%), and mesenteric
Lower gastrointestinal hemorrhage
The incidence of acute lower gastrointestinal hemorrhage increases with age and is more common in men. This is in accordance with the increasing incidence of diverticulosis, angiodysplasia, and neoplasia in the older population.240, 241, 242, 243, 244 Approximately 80% of patients with gastrointestinal bleeding pass blood in some form through the rectum.245
Only 24% of acute gastrointestinal bleeding is from the lower gastrointestinal tract.246 The annual incidence of acute lower
Endoscopic therapy in lower gastrointestinal hemorrhage
Thermal contact probes and Nd:YAG laser have been used extensively in the treatment of angiodysplasia.250, 251, 252 In 1 study, colonic angiodysplasia was treated effectively with Nd:YAG laser in 23 patients, after a mean of 2.8 sessions. No complications occurred, and only 4 recurrences were noted during a 2-year follow-up period. All recurrences were treated successfully at repeat colonoscopy.253 In the case of larger lesions, it is recommended that the periphery be treated first, to
Endoscopic treatment of malignant esophageal strictures
Cancer of the esophagus represents 1.0% of all cancers that are diagnosed in the United States and accounts for 2.1% of all deaths from cancer.266 Cancer of the esophagus or cardia in the United States occurs in approximately 6 of 100,000 men and in 1.5 of 100,000 women. Most patients with esophageal cancer have locally advanced or metastatic disease at the time of examination. The quality of swallowing determines the overall quality of life, particularly in the early stages of malignant
Endoscopic treatment of malignant gastroduodenal obstruction
Malignant obstruction of the stomach or duodenum is a preterminal event that causes nausea, vomiting, dysphagia, and electrolytic imbalance that leads to progressive deterioration of the patient's quality of life. Causes include primary tumors of the stomach and duodenum, malignant infiltration by neoplasms from adjacent organs (eg, pancreas, ampulla, distal bile duct), and compression by malignant regional lymphadenopathy. Nonsurgical palliation with endoluminal techniques (such as endoluminal
Endoprosthesis for colonic strictures
In recent years, stents have been used increasingly to relieve obstruction and treat strictures in the gastrointestinal tract. Their application is well known in vascular surgery, in the treatment of portal hypertension with the use of transjugular intrahepatic portosystemic shunting, urologic applications, and upper gastrointestinal strictures that include esophageal, duodenal, biliary, and pancreatic strictures. Plastic polyethylene stents are used in temporary situations; metallic,
Endosonography
EUS is rapidly proving to be an invaluable diagnostic tool in the hands of the clinician. EUS of the gastrointestinal tract is a method by which a high frequency ultrasound probe is inserted endoscopically to image the target organ and its surroundings. The ultrasound transducer can be placed either directly on the mucosal surface or by filling the hollow viscus (or gastrointestinal lumen) with water. Ultrasonography can be performed along the path that is traversed by the endoscope (eg,
Endoscopic treatment of gastroesophageal reflux disease
New developments in gastroesophageal reflux disease treatment include the endoscopic use of radiofrequency energy and endoscopic suture plication of the gastroesophageal junction. These 2 new techniques have undergone trial testing and have been approved by the United States Food and Drug Administration over the past year. Each uses a very different technique and approach for the endoscopic control of reflux.
Radiofrequency energy delivery to the gastroesophageal junction, the Stretta procedure,
Photodynamic therapy
Photodynamic therapy is a new cancer treatment that allows for the destruction of cancer cells with preservation of underlying normal tissue. The technique involves the injection of a photosensitizing drug that is concentrated in tumors, followed by the delivery of light at a specified wavelength. Cancers that have been investigated and found to be amenable to photodynamic therapy include esophageal cancer, lung cancer, head and neck cancer, recurrent cutaneous breast cancer, brain tumors,
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