ENDOSCOPY LABORATORY

ERCP

ERCP is applied by specialized invasive endoscopes in the presence of an anesthesiologist in a special radioscopy room of the Clinic. Metropolitan General has a state-of-the-art, fully digital remote-controlled X-ray machine with a flat digital detector (flat panel) which provides the best image quality and high resolution, with the least possible dose of radiation.

- Diagnostic (although the use of Endoscopic Ultrasound (EUS) and Magnetic Regression Cholangiopancreatography (MRCP) is preferred for both safety and increased accuracy)

- Interventional ERCP (clamping-stone removal-lithotripsy-placement of plastic and metal self-expanding stents - installation of drains)

ENDOSCOPIC ULTRASOUND (EUS)

What is Endoscopic Ultrasound?

Endoscopic ultrasound or EUS is an innovative method, which combines endoscopy and ultrasound.

It is performed with special endoscopes, which have an ultrasound transducer at their tip. During the ultrasound-assisted endoscopy of the upper or lower gastrointestinal tract, we have the ability to examine in great detail both the structure of the gastrointestinal wall, and neighboring tissues and organs, as for example the pancreas, liver, spleen, bile ducts, lymph nodes, vessels, et al.

Advanced endoscopic ultrasound system

Metropolitan General has the most advanced endoscopic ultrasound system in Greece, combining the last generation Pentax EUS J10 endoscope with the Hitachi Arietta V60 ultrasound platform.

The Pentax EUS J10 endoscope design offers increased flexibility, precision and greater handling, thus improving diagnosis, treatment efficiency and safety.
Its ergonomics guarantees increased stability and intubation ease, while the Pentax-Hitachi image resolution features incomparable imaging quality rendering precise diagnostic results.

In addition to classic ultrasound tomography, our system is capable of using contrast-enhanced EUS for maximum diagnostic precision, as well as third-generation elastography for assessment of tissue firmness.

Where is this method better?

The possibility to place the ultrasound transducer in close proximity to the organs and tissues that we want to study, gives us images of extremely high definition. Thus, endoscopic ultrasound (echoendoscopy) has the ability to clarify and better describe findings from other imaging modalities, such as CT scans or M.R.I, with great precision and to locate frequently small lesions of a few millimeters, which do not appear in classic imaging methods.

Fine needle biopsies

With endoscopic ultrasound we can collect specimens from tissues, cystic or solid masses, with the help of an ultrasound-guided fine needle. Then, the specimens we collect can be studied by a specialized physician in order to make the diagnosis. This procedure is called Fine Needle Aspiration – FNA or Fine Needle Biopsy – FNB) and in comparison to other methods is less invasive and thus safer.

Cutting-edge technology

It is known that some diseases such as cancer, result in increased tissue hardness. The modern Endoscopic Ultrasound device at Metropolitan General has the possibility of Elastography, an innovative technique, with which we can perceive the hardness of the tissues that we examine; an additional piece of information, which can aid the diagnosis. With the help of Elastography, we can guide the biopsy needle to the hardest point of the lesion we study and maximize the possibility for a successful diagnosis.

Also, the equipment of the department allows the use of intravenous microbubbles, which act as contrast agents and facilitate the identification and localization of suspicious lesions, which may not be visible with conventional methods.

How is the Endoscopic Ultrasound performed?

The Endoscopic Ultrasound is performed, with the patient under conscious sedation. In this way, the examination is comfortable for the patient and the procedure of biopsy is painless. Most of the times, the patient can return home the same day after the completion of the examination and he may receive the results immediately. However, in case that a biopsy was taken, there is a delay of few days until the completion of the cytological or histological examination.

Diagnostic Applications

• Diagnosis and staging of esophageal, gastric, pancreatic, and rectal cancer.
• Lung cancer staging.
• Assessment of chronic pancreatitis.
• Assessment of pancreatic cysts and masses.
• Investigation of biliary diseases, such as lithiasis or tumors of the gallbladder, the bile ducts, or the liver.
• Investigation of fecal incontinence.
• Investigation of submucosal tumors of gastrointestinal tract.
• Investigation of enlarged lymph nodes.

Therapeutic Applications

• Drainage of cysts and abscesses.
• Drainage of necrotic pancreatic collections and pseudocysts.
• Placement of metal indicators (fiducials) for guided / targeted radiotherapy.
• Celiac plexus neurolysis (in case of inoperable pancreatic cancer as palliative therapy for pain).

Head of Endoscopic Ultrasound Department: Dimitrios Panagiotakopoulos Gastroenterologist

SPIRAL ENTEROSCOPY

The most recent advancement in the field of enteroscopy is Spiral Enteroscopy, an Olympus technological innovation that was approved in Europe in March 2019 and is so far used only in a few centers in Europe. In Greece, Μetropolitan General was the first medical institution in Athens to install the Olympus Power Spiral endoscopic system, which is exclusively used by specially trained doctors of our hospital.

What is Spiral Enteroscopy?

Standard enteroscopy (Push Enteroscopy) is performed with lengthy endoscopes, is painful, presents complications, is usually insufficient and, thus, has practically been abandoned. Over the past 20 years, it has been replaced by double-balloon enteroscopy, a technique also challenging and time-consuming.

The Power Spiral enteroscope is the most cutting-edge tool in a gastroenterologist’s toolkit for investigating and treating small intestine diseases.

How is it performed?

The examination is performed under conscious sedation or general anesthesia. First, an endoscope is advanced with the help of a mechanical rotating coil into the small intestine. Next, under the endoscope's guidance, the lumen of the small intestine is thoroughly examined. If any lesion is found, intervention can be done through the working channel of the enteroscope, i.e., biopsy, polypectomy, cautery hemostasis or endoscopic clip placement, endoscopic tattooing, and other endoscopic interventions.

Advantages

The main advantages of this approach include smooth and safe advancement of the endoscope into the small intestine, accuracy in locating lesions thanks to the endoscope's high-definition image and stability, and, most of all, quickness in examining the small intestine along with the possibility of therapeutic intervention. Compared to double-balloon enteroscopy, Spiral Enteroscopy has reduced examination time by 53% and provides similar diagnostic accuracy.

What are the indications for Spiral Enteroscopy?

Evidence-based indications

• GI bleeding of unknown etiology
• Small intestine cancers
• Polyposis syndromes (e.g., Peutz-Jeghers syndrome, Familial Adenomatous Polyposis)
• Investigation of findings after wireless capsule endoscopy or enterography
• Foreign body retrieval from the small intestine
• Dilatation of small bowel strictures
• Incomplete colonoscopy due to anatomical difficulties

Potential indications

• Crohn’s disease
• Malabsorption investigation
• Complex polypectomies
• Percutaneous endoscopic jejunostomy
• ERCP (endoscopic retrograde cholangiopancreatography) in previously operated patients (e.g., bariatric surgery)