Platinum Health, LLC.: Pancreas & Biliary
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Pancreas and Biliary Tract
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Pancreas and biliary disease is relatively uncommon and can be complex and challenging to manage. Dr. Yakshe has unique training and experience in endoscopic retrograde cholangiopancreatography (ERCP)and the management of pancreatobiliary disease.
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Post-cholecystectomy Cholangiogram
ERCP (endoscopic retrograde cholangiopancreatography) is a procedure used to indentify problems in the pancreatic or biliary ductal system. This image shows a normal biliary tree in a patient who has had their gallbladder removed. The pancreatic duct has a developmental variant called pancreas divisum.
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Stones in the Bile Duct (Choledocholithiasis)
This cholangiogram shows multiple stones in the common bile duct, like peas in a pod. The opening to the duct was enlarged by a technique called sphincterotomy, and a balloon tipped catheter is being inserted to remove the stones from the duct.
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Large Bile Duct Stone
In this image, a balloon tipped catheter is used to occlude the outflow of dye from the ductal system and get a better image of the ductal system. A large filling defect is present in the common hepatic duct. This is a large stone, and it cannot be removed by the usual balloon extraction technique.
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Mechanical Lithotripsy
A mechanical lithotripter is inserted into the bile duct. This consists of a four wire basket that opens and engulfs the stone. When the basket is closed, the stone is fractured into smaller pieces that can then be removed from the biliary tract.
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Percutaneous Choledochoscopy and Lithotripsy
This ninety two year old lady with severe aortic stenosis had recurrent biliary type pain and elevation of liver enzymes. Abdominal ultrasound showed a dilated biliary system. Routine ERCP was not possible because of prior surgery (Roux-en-Y). In collaboration with Interventional Radiology and Anesthesiology, we punctured into her bile duct through the liver and identified a large stone (note large filling defect). We then enlarged the tract, inserted a small scope to look inside the duct and brake up the stone using a technique called electrohydraulic lithotripsy and remove it from the bile duct. All this was done under conscious sedation under careful monitoring in the operating room.
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Malignant Obstruction of the Bile Duct
This cholangiogram shows a bile duct that is strictured by a malignant tumor in the head of the pancreas. This disease typically blocks the flow of bile down the biliary tree, causing the patient to become jaundiced (yellow eyes and skin).
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Palliative Stenting of Bile Duct Obstruction
The obstruction is palliated by placing a stent through the stricture. This relieves the obstruction, allows bile to flow into the intestine, alleviating the jaundice, itching and malabsorption typically experienced by these patients.
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Pancreatic Duct Leak
This patient with abdominal pain and distension following abdominal surgery. The pancreatogram shows an injury to the tail of the pancreas, with contrast extravasating into the abdomen at the site of the leak (arrow).
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Nasopancreatic Tube
In this photograph, a tube through the nose comes down the esophagus, through the stomach, into the duodenum and into the pancreatic duct. It is attached to bulb suction externally. By constantly removing pancreatic fluid, it allows the site of the pancreatic injury to heal.
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Pancreatic Leak "Before"
This pancreatogram shows a subtle leak from the tail of the pancreas in a patient who had his spleen removed after abdominal trauma. Leakage of fluid into the abdomen was causing abdominal pain and distention for several weeks.
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Pancreatic Leak "After"
Nine days after placement of the nasopancreatic tube, the leak site has healed (no dye extravasates from the duct). The tube was removed and the patient has done well ever since.
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Communicating Pseudocyst "Before"
Following an attack of acute pancreatitis, this patient developed a small to medium sized pseudocyst causing persistent abdominal pain. Note that the pseudocyst communicates with the main pancreatic ductal system. A communicating pseudocyst in the head or body of the pancreas may respond to transpapillary stenting (by disabling the pancreatic sphincter from occluding the outflow of pancreatic juice from the duct).
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Communicating Pseudocyst "After"
There is a dramatic decrease in the size of the pseudocyst after a period of transpapillary stenting. The tool being used in this picture is a measuring catheter.
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Pancreatic Pseudocyst "Before"
This CT scan of the abdomen shows a patient with chronic pancreatitis. This patient suffered from abdominal pain, abdominal distension, early satiety and weight loss. A stone in the head of the pancreas had calcified within the duct, blocking the flow of pancreatic fluid, eroding the wall of the duct and allowing pancreatic fluid to leak into the abdomen where it formed a pseudocyst. It was not amenable to transpapillary stenting.
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Pancreatic Pseudocyst "After"
After placing a stent through the wall of the duodenum and into the pseudocyst, the contents of the cyst were able to drain internally. The abdominal pain and distention experienced by the patient were immediately relieved and she soon regained the weight she had lost. The cyst did not recur during a two year followup after removal of the stent.
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Non-Communicating Pseudocyst and Transgastric Endoscopic Pseudocystgastrostomy
This patient had a large pseudocyst behind the stomach and the main ductal system did not communicate with the pseudocyst. Fortunately, the cyst was causing an extrinsic compression of the stomach and was ideally suited for endoscopic management. From inside the stomach, two stents were endoscopically placed through the stomach wall and into the center of the pseudocyst, allowing its contents to drain internally. This procedure allowed us to deal with his problem without the need for surgical intervention.
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