Advanced Endoscopic Procedures: From Diagnosis to Minimally Invasive Treatments

SINGAPORE,May 5,2023 --Endoscopy has come a long way since its inception in the mid-1800's. Various technological advancements within the realm of gastroenterology and hepatology have allowed the scope to reach deep-seated organs or examine long structures,like the intestines. "Advanced endoscopy" procedures are those which require additional training over and above general endoscopy procedures. These procedures provide a minimally invasive alternative to treating certain conditions that would have otherwise required conventional open surgery.

Dr Benjamin Yip is an experienced Consultant Gastroenterologist and the Medical Director of the Alpha Digestive & Liver Centre.

In this article,Dr Benjamin Yip,Consultant Gastroenterologist and Medical Director of Alpha Digestive & Liver Centre,tells us more about advanced endoscopic procedures and their potentially life-saving functions.

Endoscopic Ultrasound (EUS)

An endoscopic ultrasound (EUS) is a minimally invasive endoscopic procedure that involves the use of an ultrasound scanning probe attached to the tip of the endoscope. It allows the gastroenterologist to examine the lining of the upper (oesophagus,stomach and duodenum) and lower (sigmoid colon and rectum) gastrointestinal tract,as well as the structures next to the GI tract such as lymph nodes,tumours,collections,the pancreas,liver,gallbladder and bile duct.

Diagnostic purposes

EUS can be used to diagnose diseases,including:

Bile duct stones

Pancreatic cysts

Any form of cancer in the digestive tract (oesophagus,stomach,rectum,pancreas)

Any abnormal growths in the digestive tract (stomach,oesophagus,rectum)

Lymphoma and enlarged lymph nodes in the abdomen and chest

Tissue can also be obtained via fine-needle aspiration (biopsy) for a more detailed analysis to aid in diagnosis.

Therapeutic purposes

EUS can be used to treat certain medical conditions without the need to make a cut on the body and perform surgery. These include:

Drainage of pancreatic cysts

Aspiration of fluid-filled spaces in the abdomen

Treating any bleeding in the digestive tract from a burst blood vessel

For treatment of pancreatic diseases,via applying nerve blocks

Various ablative therapies

In Dr Benjamin Yip's personal opinion,the EUS is a procedure tailor-made for the pancreas,which is a deep-seated abdominal organ often obstructed by other organs and structures.

For both diagnostic and therapeutic purposes,an EUS allows the gastroenterologist to access the pancreas (given the configuration of the stomach and duodenum) in a minimally invasive manner. Otherwise,access to the pancreas would generally be performed percutaneously (via the skin),which would often not be possible due to the inaccessibility of the pancreas.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic procedure used to look at or treat the bile ducts,pancreatic ducts and gallbladder.

During the ERCP,a thin,flexible,and hollow tube with a camera attached at one end,called an endoscope,is inserted through the mouth and carefully moved into the digestive tract. The endoscope goes from the mouth to the oesophagus,and then lastly to the duodenum,the first part of the small intestine.

Diagnostic purposes

ERCPs may be used to evaluate certain conditions:

Biliary tract abnormalities

Dilation of the bile duct

Bile duct obstruction (causes include gallstones)

Evaluating narrowed segments,also known as strictures,of the bile ducts

Cancer in the liver,pancreas,or gallbladder

Infections of the bile ducts

Primary sclerosing cholangitis

A sample of tissue or cells may also be removed (biopsy/brushing) during the ERCP to be sent to the lab for further analysis by a pathologist

Therapeutic purposes

ERCPs may be used to treat certain conditions of the bile ducts and pancreatic ducts. It may also be used to treat complications after gallbladder or liver surgery.

Gallstone extraction

Insertion of a stent to relieve blockage

Dilation of strictures

Endoscopic sphincterotomy (opening up the entry of the ducts into the bowel)

Drain blocked areas

Dr Benjamin Yip shares,"Although ERCP is one of the higher risk endoscopic procedures,it is usually well-tolerated. I had a patient in her 90's with incurable ampullary cancer,in which I did ERCP and inserted a biliary metal stent to prevent biliary blockage. I remember seeing her one year after the ERCP,and she remained well,and the stent was functioning well!"

Deep Enteroscopy

Deep enteroscopy is an incisionless procedure whereby a long endoscope is inserted into the gastrointestinal tract. A common type is balloon-assisted enteroscopy,which makes use of small balloons to allow an endoscope to effectively travel through the small intestine,which is typically hard to reach. After the endoscope is inserted through the mouth (antegrade approach),the balloons are alternately inflated and deflated,allowing movement through the gastrointestinal tract. For the retrograde approach,the endoscope is inserted through the anus.

On average,the small intestine is six metres long,making it difficult to reach using more-traditional endoscopy procedures. Deep enteroscopy works by "pleating" the intestine as the endoscope is threaded through it,which can be likened to pushing a rod through a curtain.

Diagnostic

Deep enteroscopy could be used as a diagnostic tool to:

Find the cause of bleeding in the small intestine

Detect and biopsy strictures (abnormal narrowings,inflammation or scar tissue)

Detect and biopsy abnormal tissue

Detect and biopsy polyps or tumours

Therapeutic

Deep enteroscopy serves a therapeutic purpose,and various miniature tools can be attached to the end of the endoscope to:

Stop the bleeding

Remove polyps within the small intestine

Widen a stricture

Remove a foreign body stuck in the small intestine

Implant a stent to prevent the re-narrowing of a section in the small intestine

The small bowel used to be a "no man's land" for Gastroenterologists as they are deep within the abdomen and were difficult to reach with the instruments of the past. Nowadays,however,modern endoscopes with various capabilities allow the Gastroenterologist to access these difficult-to-reach areas — sometimes saving the patient from having to undergo surgery.

About Dr Benjamin Yip

Dr Benjamin Yip is an experienced Consultant Gastroenterologist and the Medical Director of Alpha Digestive & Liver Centre.

Dr Benjamin Yip sees patients with General Medical as well as Gastroenterology/Hepatology problems. His main interest and joy lies in endoscopy. He regularly performs general endoscopies such as gastroscopy and colonoscopy (both diagnostic and therapeutic). However,his expertise lies in Advanced Endoscopy,where he performs complex endoscopic procedures,including ERCP,EUS,deep enteroscopy,SpyglassTM cholangioscopy and enteral dilation/stenting.

Prior to his private practice,Dr Yip served in the public sector for almost two decades. He was appointed Consultant at Khoo Teck Puat Hospital (KTPH) as well as Ng Teng Fong General Hospital (NTFGH). He is currently still a Visiting Consultant at NTFGH.

About Alpha Digestive & Liver Centre

The Alpha Digestive & Liver Clinic is led by Consultant Gastroenterologist,Dr Benjamin Yip. The term "Alpha" was inspired by the first letter of the classical Greek alphabet and the first number. Similarly,the Alpha Digestive & Liver Clinic strives to be your first point of contact for any gastrointestinal conditions,from comprehensive screening services to diagnostic tests and minimally invasive treatment procedures.

Dr Yip believes that gastrointestinal health is hugely interconnected to our whole-body health and sees patients with General Medical,as well as Gastroenterology and Hepatology problems. With that in mind,the clinic places great emphasis in caring for all aspects of your gut health — from preventative measures to personalised treatment plans with minimally invasive treatment procedures.

Alongside an experienced team,the Alpha Digestive & Liver Clinic provides gut health management advice,prompt scheduling services,diagnostic tests and treatment plans tailored to patients with all needs and concerns.

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