Gastroenterology & GI Endoscopy

Endoscopic procedures like EUS and ERCP are becoming increasingly more important in the process of diagnosing pancreatic cancer. Advanced equipment and innovative techniques are now enabling physicians to visualize the pancreas with precision never achieved before. When performed by a skilled endoscopist, these procedures can provide improved imaging resolution of the pancreas and provide a reliable diagnosis.

The Pancreas Center receives referrals from a number of primary care physicians and gastroenterologists. The endoscopic reports we receive become the first diagnostic tool used for the patient work up. For those patients who do not have access to the most advanced endoscopy options, we refer patients to our Pancreas Center endoscopists. In recent years, the GI endoscopy physicians have performed over 1,500 EUS and ERCP procedures each year.

Pancreas Center GI/Endoscopy Team

Vasudha Dhar, MD
212.305.1909

Charles Lightdale, MD
212.305.3423

Leslie Schmidt, NP
212.305.3955

EUS & ERCP

The endoscopists in the Pancreas Center are able to perform endoscopic ultrasound, with fine needle aspiration or injection (FNA/I) as needed, for a variety of diagnostic and therapeutic indications. The most common indications for EUS are for pancreatic cysts and suspected pancreatic cystic and solid tumors. For patients with pancreatic cysts, imaging with EUS is complemented by analysis of cyst fluid for cytology, tumor markers, and genetic mutational analysis. Inflammatory diseases of the pancreas, including acute and chronic pancreatitis, are evaluated by EUS. In some cases secretin stimulation of pancreatic secretions is used during the examinations to better visualize ductal anatomy and to evaluate pancreatic function.

Therapeutic indications for EUS include drainage of pancreatic and peripancreatic fluid collections, injection of the celiac plexus for pain control, and most recently for EUS/ERCP rendezvous procedures (ERVP). ERVP harnesses the power of EUS to provide access to bile and pancreatic ducts under fluoroscopy to facilitate therapeutic ERCP procedures. In these procedures the ducts of interest are first accessed via a direct transduodenal or transgastic route when standard ERCP access techniques fail due to difficult or surgically altered anatomy.

ERCP

High quality ERCP is available to many patients through their own gastroenterologists. If you feel your patient would benefit from our consultation, and outside films of these procedures are available, patients and referring physicians are encouraged to forward the films with the patient for review. Additionally, the Pancreas Center offers a full range of advanced diagnostic and therapeutic ERCP procedures that may not be available locally.

Innovative Procedures

Intraductal Ultrasound (IDUS)

Though many endoscopists perform EUS on patients regularly, IDUS is used by endoscopic gastroenterologists at the Pancreas Center to better visualize tumors and cysts within the pancreas gland itself. IDUS uses mini probes less than 2 mm in size which can be passed through standard endoscopes directly into pancreatic ducts for more accurate, higher resolution images.

Choledochoscopy and Pancreatoscopy

Pancreas Center endoscopists frequently employ the latest technology for evaluation of the bile and pancreatic ducts with direct visualization using the SpyGlassTM Direct Visualization System for singleoperator duodenoscope assisted cholangiopancreatoscopy (SODAC). This procedure allows visually directed diagnostic and therapeutic interventions. It is especially useful in difficult-to-access ducts of patients with indeterminant biliary and pancreatic strictures, premalignant lesions such as IPMN, and difficult to manage stones.

Altered Anatomy ERCP: Double Balloon and Minimal Access Surgery Techniques

For patients with difficult post-surgical anatomy (long afferent limbs after Whipple, Billroth II, Roux Y hepaticojejunostomy, and gastric bypass operations) who are not candidates for endoscopic rendezvous procedures, ERCP can now often be accomplished with standard ERCP accessories using a double-balloon endoscopy system. When this is not possible, Pancreas Center endoscopists and surgeons team together to use minimal access surgery techniques to provide ERCP access.

Research Initiatives

Active Studies

  • Use of novel molecular markers in the assessment of malignant potential in clinically lower risk lesions
    • Retrospective review in small low risk lesions
    • Use of measurement of DNA quality/quantity/presence of K-ras mutations/LOH
  • Role of EUS based surveillance strategies
    • Retrospective review of 10 years of experience with EUS of pancreatic cystic lesions
    • IRB approved protocol to establish comprehensive database
    • Prospective database of EUS surveillance and cyst fluid bank
      • Use of genetic and epigenetic markers

Clinical Questions

  • Molecular diagnostic tools for indeterminate lesions
  • Molecular treatment of pancreatic cancer
  • Optimize stent strategy for neoadjuvant patients through quality of life and cost analysis
  • Improving cyst surveillance strategies
    • Impact of molecular medicine including (RedPATH)
    • Role of injectable therapeutics

Recent GI Endoscopy Publications

  • Stevens PD, Chen YK, Pleskow D, Haluszka O, Peterson B. Biliary Stone Extraction (BSE) Guided By Direct Visualization Using the New SpyGlassTM Direct Visualization System. Gastrointestinal Endoscopy. 65(5):AB96-AB96.
  • Stavropoulos S, Larghi A, Verna E, Battezzati P, Stevens P. Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography. Endoscopy. 2005 Aug;37(8):715-21.
  • Stavropoulos S, Larghi A, Verna E, Stevens P, Therapeutic endoscopic retrograde cholangiopancreatography without fluoroscopy in four critically ill patients using wire-guided intraductal ultrasound. Endoscopy. 2005 April;37(4):389-92.
  • Larghi A, Verna EC, Stavropoulos SN, Rotterdam H, Lightdale CJ, Stevens PD. EUS-guided trucut needle biopsies in patients with solid pancreatic masses: a prospec-tive study. Gastrointest Endosc. 2004;59(2):185-90.
  • Stevens PD. EUS of the pancreas. In: Gress FG, Bhattacharya I, Eds. Endoscopic Ultrasonography. Blackwell Science; 2001.