Procedures

Endoscopy
Endoscopy is any procedure that uses an endoscope which is a thin, flexible, lighted tube with a small camera on the tip. The camera is connected to a video monitor that displays the images produced by the endoscope. In gastrointestinal endoscopy, the endoscope is inserted through the anus or mouth.

An endoscope allows a physician to look directly at the inside lining of the digestive tract and can be used for diagnosing, and in some cases treating, gastrointestinal diseases. Types of gastrointestinal endoscopy include colonoscopy, upper endoscopy, capsule endoscopy, ERCP (endoscopic retrograde cholangiopancreaticography) and endoscopic ultrasound.

Capsule Endoscopy
Capsule endoscopy is advanced technology for allowing detection of disorders in the small intestine, an area that can not be visualized with a conventional endoscope. The capsule used in the procedure is approximately the size of a large vitamin and packs a camera, light source, radio transmitter and battery.

The "camera in a pill" is swallowed and passes naturally through the digestive tract, recording video images every 2 seconds that are transmitted to and stored on a recorder belt worn by the patient throughout the day. The patient is able to continue their normal daily activities, and after approximately eight hours, the patient returns the recording device to the hospital. The physician can then view thousands of images via an imaging workstation equipped with special software. The single use capsule is eliminated naturally and is not digested or absorbed by the body.

Although not a substitute for gastrointestinal endoscopy, capsule endoscopy provides an additional tool for diagnosing gastrointestinal disorders, including bleeding, abdominal pain, and diseases such as tumors, Crohn's disease, infectious enteritis, celiac sprue and drug-induced ulceration.

Bravo pH Study
A Bravo pH study is used in diagnosing gastroesophageal reflux disease (GERD), which is the leading cause of chronic heartburn. The study allows a physician to evaluate heartburn symptoms to determine the frequency and amount of acid refluxing into the esophagus.

Traditionally, acid levels in the esophagus are measured by placing a catheter, which is connected to a monitor on the patient's belt, down the nose and into the esophagus for a 24-hour period. The catheter can be uncomfortable and can limit a patient's activities.

Bravo is a convenient and comfortable new catheter-free pH monitoring system offered at Presbyterian Hospital of Dallas that allows patients to maintain their regular diet and activities. The test involves a small pH capsule, approximately the size of a gelcap, that is attached to the wall of the esophagus, usually through a routine endoscopy procedure.

This minimally invasive monitoring system collects pH data over a 24- to 48-hour period and transmits the information to a pager-sized receiver worn on the patient's waistband. The patient is asked to keep a diary to write down physical activities, when and what they eat, when they sleep and when they experience reflux symptoms, such as coughing, heartburn or regurgitation.

This diary, along with the data from the Bravo capsule, is analyzed, and a comprehensive report is created for the physician. Several days after the test, the capsule naturally falls off the wall of the esophagus, passes through the digestive tract and is eliminated naturally.

ERCP
ERCP (endoscopic retrograde cholangiopancreatography) is an endoscopic procedure primarily used to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery) and cancer.

What is bile?
Among its many functions, the liver makes bile, a liquid that helps with digestion. Some of the bile secreted by the liver is collected by the biliary system and passed directly to the small intestine. Extra bile is stored in the gallbladder until needed; then it passes to the small intestine through the common bile duct. Bile from the common bile duct flows into the duodenum (first part of the small intestine) through the same opening as digestive enzymes from the pancreas, which are carried by the pancreatic duct.

Evaluating Ducts, Pancreas
For an ERCP procedure, a special thin, flexible tube, called an endoscope, is inserted through the mouth into the small intestine. A dye is injected into the bile ducts and pancreas through the endoscope. X-rays are then taken to be used to evaluate the ducts and pancreas.

Special instruments can be placed through the endoscope into the ducts to open the entry of the ducts into the bowel, stretch out narrow segments, remove or relieve an obstruction and take tissue samples.

Endoscopic Ultrasound
Endoscopic ultrasound combines endoscopy and ultrasound to obtain information and images about the digestive tract and surrounding tissues and organs. Ultrasound is a technique that uses sound waves to create a picture of the inside of the body. An endoscope is a thin, flexible, lighted tube that can be inserted through the mouth or rectum to view the digestive tract. The endoscope displays images on a video monitor.

Endoscopic ultrasound is a technique that uses an endoscope with a small transducer (a device that receives and sends ultrasound signals) on the tip. Endoscopic ultrasound allows a physician to place the ultrasound transducer inside the body very close to the area of interest to produce more detailed images than a standard ultrasound.

Endoscopic ultrasound is a diagnostic tool that can be used to:

• Study the spread of local gastrointestinal cancers
• Evaluate fistulas (abnormal channels or loops) in the rectal area
• Study lesions in the gastrointestinal tract that are below the surface
• Evaluate the pancreas
• Study bile duct abnormalities

Laparoscopic Colon Surgery
Laparoscopic colon surgery is a minimally invasive technique used by physicians on the medical staff at Presbyterian Hospital of Dallas for treating colon disorders. Traditionally, colon surgery is performed using a large incision that runs up and down the length of the abdomen. The problem section of the colon is removed, and the two ends of the bowel can then be joined back together.

Laparoscopic colon surgery is performed through five or six small incisions in the abdomen. A laparoscope, a thin, lighted tube with a tiny camera on the end, is inserted through one of the incisions. During the procedure, the surgeon is guided by the laparoscope, which transmits images to a video monitor. Small surgical instruments are inserted through the other incisions and are used to remove the diseased section of the bowel and to reattach the two ends of the bowel. Advantages of laparoscopic colon surgery, as compared to traditional colon surgery, can include:

• Shorter hospitalization
• Quicker recovery
• Less pain
• Smaller scar
• Quicker return to normal activities

Physicians on the medical staff at Presbyterian Hospital of Dallas can use laparoscopic colon surgery to treat the following:

• Crohn's disease
• Some colorectal cancers
• Diverticulitis
• Ulcerative colitis
• Polyps that cannot be removed through colonoscopy

Whipple Procedure (pancreaticoduodenectomy)
The Whipple procedure, also called a pancreaticoduodenectomy, is one of the most complex and demanding operations being performed today. It involves the removal of part of the pancreas, as well as part of the stomach, the gallbladder and the duodenum (first part of the small intestine), a small part of the second part of the small intestine (the jejunum), lymph nodes near the pancreas and part of the common bile duct. The remaining bile duct is attached to the small intestine so that bile from the liver can continue to enter the small intestine.

The procedure is used to treat a tumor of the pancreas, a tumor of the bile duct or inflammation of the pancreas or pancreatitis.

Surgeons on the medical staff at Presbyterian Hospital of Dallas' Hepatobiliary and Pancreatic Disease Program perform more Whipple procedures than any hospital in North Texas, more than any other local hospital and as many or more than most nationally.

The American Cancer Society emphasizes the importance of finding experienced physicians to perform the Whipple Procedure. "For patients to have the most successful outcomes, they must be treated by a surgeon who has performed many of these operations and at a hospital that has had extensive experience with pancreatic surgery," according to the American Cancer Society.

Helping with Digestion
The pancreas, a gland located behind the stomach, makes fluids that aid digestion. Endocrine cells in the pancreas produce insulin to regulate blood sugar levels. Another part of the organ makes enzymes that help digest fats and proteins. These digestive enzymes are carried by the pancreatic duct and emptied into the first part of the small intestine (duodenum).

Among its many functions, the liver makes bile, a liquid that helps with digestion. Some of the bile secreted by the liver is collected by the biliary system and passed directly to the small intestine. Extra bile is stored in the gallbladder until needed; then it passes to the small intestine through the common bile duct. Bile from the common bile duct flows into the duodenum through the same opening as the digestive enzymes from the pancreas.

If a tumor develops in the head of the pancreas, it can block the common bile duct, and a Whipple Procedure may be recommended for treatment.

Radiofrequency ablation of liver tumors
Radiofrequency ablation is a local (rather than systemic) treatment for destroying cancerous tumors in the liver. The procedure gives hope to cancer patients with otherwise inoperable liver tumors and provides an option to individuals who may not tolerate major surgery or who do not respond to other treatments.

During the procedure, a special needle electrode is placed in the tumor under the guidance of ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI). Radiofrequency waves are passed through the electrode to heat and then destroy cancerous growths with little affect on the surrounding healthy liver tissue. The dead tumor cells are gradually replaced by scar tissue that shrinks over time.

Radiofrequency ablation is primarily used for two types of liver tumor: hepatocellular carcinoma (a primary liver cancer) and colon cancer that spreads (metastasizes) to the liver. The procedure can be used alone or in combination with other treatments, including surgery, chemotherapy and chemoembolization.

Radiofrequency ablation is an outpatient procedure, and most patients can resume normal activities within a few days. The procedure is less invasive and produces fewer complications than open surgery, and the procedure can be repeated as needed should tumors reoccur.