Understanding the Use of Advanced Gastrointestinal Interventional Endoscopy with Dr. Prabhleen Chahal

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. So, welcome to another episode of Butts & Guts.

I'm your host Scott Steele, the chairman of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And we're very pleased today to have Dr. Prabhleen Chahal, who is one of our staff gastroenterologists and an expert in interventional endoscopy. Prabhleen, welcome to Butts & Guts.

Prabhleen Chahal: Thank you so much, Scott. Happy to be here.

Scott Steele: So, for all of our listeners out there. We normally start off by you telling us a little bit about yourself, where were you born and how did it come to the point that you wound up here in Cleveland?

Prabhleen Chahal: So, I was born and brought up in India. I did my medical school in India. After finishing my medical school I came to US. I did about six to eight months of research at Stanford University, followed by Internal Medicine Residency, GI Fellowship, and then year of Advanced Endoscopy Fellowship at Mayo Clinic, Rochester, Minnesota. After that, I was in private practice for a year in Dallas. And then I moved to Cleveland. I've been here for little over eight years.

Scott Steele: So, we've had all our other gastroenterologists on the program but, one of the things we haven't really talked about is some of the more advanced procedures. And so, the topic today is going to kind of focus on a little bit about advanced endoscopy. So, give us the 50 thousand foot view. What is advanced endoscopy?

Prabhleen Chahal: So, when we talk about endoscopy, the first thing that comes to our mind is colonoscopy or routine endoscopy that we do to evaluate general GI symptoms, gastroesophageal reflux, or screening for colon polyps. Advanced endoscopy is a term that we use where we use special technology accessories and equipment and allow us to manage more complex gastrointestinal, pancreas, biliary, or liver-related disorders.

Scott Steele: So, you're trying to kind of hone in on our surgeon's techniques there, through some minimally invasive natural orifice procedures?

Prabhleen Chahal: Yeah. So, yes, we can use the term natural orifice surgery but, this is all within your body and yes ... So, this is little bit cutting into surgical turf, so we do manage lot of conditions which were historically managed by surgery or by interventional radiology.

Scott Steele: That's extremely exciting, especially because it eventually relates to having a decreased percentage of complications and pain and everything else, and we'll get into that. So, you're an expert on interventional endoscopic ultrasound. So, let's talk a little bit about that. What are some applications of interventional ultrasound? What is it?

Prabhleen Chahal: So, interventional ultrasound, when we talk about EUS or endoscopic ultrasound, this technology has been with us for over 40 years. Historically, it was more of a diagnostic test. But, since past 10 to 15 years, we have transitioned into what we call is a therapeutic or interventional EUS. So, we use endoscopic ultrasound for more common reason, for example, somebody who has a mass or a growth or a lesion in the gastrointestinal tract starting from esophagus, mediastinum, stomach, pancreas, bile duct, gallbladder, enlarged lymph nodes, rectum, outside the rectum. So those areas are easily accessible and visualized by endoscopic ultrasound and allow us to do biopsy for confirmation of diagnosis. But more recently, we have pushed the envelope where we can do bile duct or pancreatic duct drainage procedures in somebody who may have had failed ERCP or they have surgically altered anatomy, which is not easy accessible with routine endoscopy.

Managing pancreatic fluid collection, so this is the most favorite approach where the expertise is available. Managing abdominal fluid collections, abscesses, postoperative fluid collections. What we call as endoscopic ultrasound-guided angiotherapy, so treatment of gastric varices, esophageal varices with EUS guidance. Creating what we call as transluminal access, so somebody who may have had gastric bypass and they need biliary or pancreatic procedures, that's a long route for routine endoscopy. So, with EUS we can create a fistula between the pouch and the gastric remnant and that allows us to perform endoscopy. Other applications include celiac plexus block or neurolysis in somebody who may have had chronic pain or pancreatic cancer-related pain. So, it's creating gastrojejunostomy, that's another new exciting development, so we can manage gastric outlet obstruction. Most of the times from malignancy, endoscopically.

Scott Steele: Wow. There's a lot to unpack there. So, let's roll it back just a little bit. So, couple of things that I heard in there. Number one, we're talking about masses and cancers and potentially getting a biopsy. But, procedures that used to have a major operation that would result in a prolonged hospital stay, you're now able to tackle through these advanced interventional endoscopic techniques to include the endoscopic ultrasound. So, when does the doctor get it to you in order that you can then intervene?

Prabhleen Chahal: That's an excellent question, Scott. I think there is still an opportunity for raising awareness about the applications of endoscopic ultrasound. They have expanded exponentially within past decade. So, if you have any issues pertaining to gastrointestinal tract, pancreas, bile duct, gallbladder, rectum, outside the rectum, I think it's probably, you won't be wrong in asking, is this something that require endoscopic ultrasound? But, more specifically, if you have any abdominal fluid collections or if pancreatitis complicated by pancreatic fluid buildup, what we call as a pseudo-cyst or necrosis, I think the procedure of choice nowadays is endoscopic ultrasound-guided management. So, ask your doctor if you have a local expertise available, or get yourself transferred or referred to a center, where this expertise is available.

We had a patient recently referred to our hospital, who had postoperative abscess right under the diaphragm. That's a very tricky location to access with percutaneous catheters by radiology. That was attempted, that ended up with punctured lung. So, patient were transferred here and that's an area which is very easily accessible with EUS guidance. We were able to go down and empty the abscess through the stomach. And patient was discharged home, second day. So, whenever you have any kind of abdominal fluid collections, you have problem with the bile duct where the endoscopy was attempted and it was unsuccessful, you have surgically altered anatomy where the access to the bile duct or pancreas may not be easy. Instead of thinking about surgery or interventional radiology, I think it's reasonable to talk to your doctor about referral to Center, which has EUS expertise available.

Scott Steele: Again, exciting stuff, especially the part about the fluid collections in tricky places. So, let's hone in a little bit more things just to clarify and just to point out. I'm somebody, I’ve got gallstones. I get pain after every time I eat. Do I need an endoscopic ultrasound or will a normal ultrasound suffice?

Prabhleen Chahal: I think for gallstones, particularly for gallstones, per se, normal ultrasound is sufficient. But if there's a concern that some of the gallstones may have spilled down into the bile duct and you may have what we call as choledocholithiasis or stones in the bile duct, that is not easily traced by trans-abdominal ultrasound. And that's where, either an MRI or endoscopic ultrasound would be a superior test to figure that out.

Scott Steele: My doctor says, "I'm going to refer you for one of these interventional endoscopic ultrasounds", or some of the more advanced endoscopic techniques. What can they expect?

Prabhleen Chahal: It's very important that patient, they're educated. What they're coming in for? What are their choices? What are the alternatives? What kind of procedure I'm proposing, why I'm proposing that. What are the risks, complications of the procedure I'm proposing? Is this superior compared to the alternatives, which usually are interventional radiology or surgery? So, the key here is getting them educated, making them aware of their options and then forming an informed decision.

Scott Steele: Okay. So, then they come in. And, take me through the technique. What actually happens? Do you have to sedate? Do you go all the way under for this? Are you in twilight? And take me through one of the upper type of endoscopic ultrasound procedures.

Prabhleen Chahal: So, the most common indication for endoscopic ultrasound is somebody where they may need a biopsy. So, let's take that as an example. Somebody with a newly diagnosed pancreatic cyst or a pancreatic mass. Usually, we do obtain routine labs, so if they are on any blood-thinning medication, we ask them to stop that at least five to seven day before the procedure. We obtain some routine blood work, like, INR, which tells us how thin their blood is. The procedure is done as an outpatient setting and it takes about an hour or so for them to get checked in for the procedure. They are seen by anesthesia, it's done under what we call as monitored anesthesia care. So, they are under deep sleep while we are doing the procedure.

The endoscopic ultrasound procedure itself can last anywhere from half an hour to 60 minutes. After the procedure, they are watched in recovery for another 30 minutes and they are able to go home afterwards. Usually, there are no restrictions. They are allowed to eat. There might be some modifications, in terms of discharge instructions. If I did biopsy of the pancreas, I may ask them to stay on low-fat diet for rest of their day after the procedure. But, most of the patients are able to go back to work the following day.

Scott Steele: So, give us a look behind the curtain. What do you actually do, when you do that? So, they go off to their twilight and is this just like people who've had an upper scope in the past or a so-called EGD or are there different types of equipment that you use? What do you do?

Prabhleen Chahal: So, excellent question, Scott. So, I do tell them about what kind of equipment I'll be using. So, it's very similar to routine upper-endoscopy. The only difference is, our flexible tube is little bit thicker, so it's about 13 millimeter. Not only it has a camera at the tip, it also has what we call as a high-frequency ultrasound probe. So, it's a combination of direct camera visualization and an ultrasound. So, when they're asleep, we go down from their mouth, esophagus, up to early small intestine. And then the ultrasound allows us to visualize the details of the GI tract, wall layers, and outside the esophagus, stomach, and small intestine and allows us to take direct biopsy. So this flexible tube has a very long biopsy channel, that allows us to pass different type of biopsy needles, stents, cautery equipment and allow us to do all the therapeutic interventions.

Scott Steele: And you said it takes about 30 to 60 minutes. And so, are there risks to this procedure? You said you went over some of the risks. What are the type of risks that can happen? And how often do they occur?

Prabhleen Chahal: Let's take an example of again, pancreatic mass or cyst, which is most common indication. The risks are very similar to routine upper-endoscopy, which include risk of perforation, which is making a puncture, tear or whole in the digestive system. It's one in six to seven thousand. The risk of bleeding from taking a biopsy from pancreatic mass or cyst is less than one in 100. The risk of causing inflammation of pancreas from pancreas biopsy, what we call as pancreatitis, is also about one in 100. And then risk of infection, if we're taking a sample from a pancreatic cyst, is again less than one in 100. But, when we do more of interventional EUS, you're draining the bile duct, you're draining the pancreatic fluid collection, then the risks go up, for example, if I'm doing what we call as a direct debridement of pancreatic necrosis, where we create a hole in the stomach to access the dead pancreas behind or around the stomach and we drive our endoscope into the cavity and manually debride the dead pancreas, the risk go high and it could be as high as 30%.

Mainly the risk would be that of bleeding and it's reported to have been about 10 to 13%. When we are doing interventional procedure, there's a risk of embolism as well, even though we use Co2, there have been a case report of air embolism, despite using Co2. So, it depends upon the intervention we are doing. The complications are probably directly proportioned to how aggressive we are being with the procedure.

Scott Steele: Yeah. It sounds like it's pretty darn safe, overall. So, for the patients that might develop a complication during this, do they have to go on and get surgery? Or, is this complications typically something that are self-limited or are there techniques that you can use in order to stop them then and there so they don't have to be rushed off to an operating room?

Prabhleen Chahal: Yes, and that has also been a dramatic change within a past decade. If there are any complications that happen, majority of them are managed endoscopically or they can be managed conservatively. It's extremely rare that patient have to undergo any kind of a surgical procedure for management of complications. Historically, any kind of a complication, including perforation, was managed surgically. But nowadays, we can manage perforations as big as two-centimeters endoscopically. We can close the hole. And if there is any bleeding, we have tools and techniques, and equipment that allow us to manage bleeding as well. If patient developed pancreatitis, the management would be more conservative. There is no medication, surgical procedure to help manage those. So, yes, we can manage majority endoscopically.

Scott Steele: Again, exciting stuff. It's always very interesting for me to hear some of the things that are happening in the interventional world that have just had such dramatic effects on our patients. So, what's on the horizon for advanced endoscopy or interventional endoscopic ultrasound? What's the next thing? Or is there anything specifically that we're doing here in Cleveland that's kind of pushing this platform forward?

Prabhleen Chahal: Yes, absolutely. I'm glad you asked this question, Scott. Endoscopic ultrasound is one technology where lot of exciting developments are happening, not only from the procedure aspect but, also the tools and technology that is being developed and allows us to push the envelope. So, one of the new things that we started doing at Cleveland Clinic is what we call as endoscopic ultrasound directed ERCP in patients with gastric bypass. Patients who have had gastric bypass, about 10 to 15% of them may go on to have problems with the bile duct or pancreas. They may have stones or bile duct may not drain properly or they may get pancreatitis episodes that require a special type of an endoscopy called ERCP. But because of the bypass access to the area where bile duct and pancreas opens is not easy, it ways, ways down.

Historically, we would use a technology called balloon endoscopy but, the success rate of balloon was only 60%. And with EUS, we are able to access the gastric remnant by placing a lumen-apposing metal stent, these are dumbbell-shaped stent. They open up to about 15 millimeter in diameter. And we place one end of the stent in the roux limb or gastric pouch, and second, under ultrasound guiding into the gastric remnants. So, basically, that allows us to recreate their normal anatomy, and now we can easily perform ERCP procedure and open up their bile duct and pancreas. Once the intervention is done, we pull the stent out and then we cauterize the area of the fistula that we had created and it closes spontaneously six to eight weeks down the road. So, this is an exciting development.

Again, historically, these were the patients we would take them to the operating room and we would do something called as a laparoscopy of DRCP, which again, it's not a simple procedure, it's obviously a surgery. So, this is something exciting we are doing. Second thing I would like to mention, is we have acquired technology called radiofrequency ablation, which allows us to treat malignant strictures in the bile duct. There are some studies that are going on by looking at these RFA for the pancreatic cyst but, they are still early data. Some of the other exciting stuff that is on the horizon is EUS guided tumor ablation, EUS guided intratumoral injection, EUS guided drainage of gallbladder, endoscopic ultrasound-guided gastrojejunostomy, the radiofrequency ablation. So, a lot of exciting stuff on the horizon.

Scott Steele: And that's all happening here in Cleveland?

Prabhleen Chahal: So, we have done EUS guided gallbladder drainage, we have done EUS guided gastrojejunostomy, we have done EUS guided access in patients with altered anatomy, we acquired radiofrequency ablation. We're part of a study looking at intertumoral injection with EUS. But, there's no current study going on as of now.

Scott Steele: Wow. That is really, really amazing. So, I always like to end up with what we call quick hitters here. So, a little bit about you so they can get to know you a little bit better. So, what's your favorite food?

Prabhleen Chahal: Indian foods, samosas.

Scott Steele: And what is your favorite sport?

Prabhleen Chahal: Tennis.

Scott Steele: And what's the last book that you read? Fun book, no medicine journals or medicine things.

Prabhleen Chahal: I'm not sure if I would call it a fun book but, the last one was read was HBRs on Emotional Intelligence.

Scott Steele: Okay, good. And then, tell us something that you like most about Cleveland?

Prabhleen Chahal: I think this is, I call it as a well-hidden gem. There is something for everyone. Whether you are sports, music, art, indoor, outdoor person, there is something for everyone. It's excellent place to raise family.

Scott Steele: That's fantastic and we're so excited and glad to have you ... I learned something today. I didn't even know some of the things that we could do here. And to learn more about interventional EUS and Cleveland Clinic’s Digestive Disease and Surgery Institute, please visit ClevelandClinic.org/Digestive. That's ClevelandClinic.org/Digestive. And to make an appointment with the Cleveland Clinic digestive specialist, please call 216.444.7000. That's 216.444.7000. Prabhleen, thanks again for joining us on Butts & Guts.

Prabhleen Chahal: Thank you so much, Scott, for having me.

Scott Steele: That wraps things up here at Cleveland Clinic, until next time. Thanks for listening to Butts & Guts.