Good morning. We are back in Juarez... For the second day of our... Interventional endoscopy symposium. I am here with my associate..
Dr. Reem Sharaiha... And we have a very interesting case. This is an 80 year old patient... With epigastric pain... Associated with nausea and vomit. The scan..
Done here before the procedure... Just a few days ago... Has revealed a lesion located..
At the junction... Of the body and... The tail of the pancreas..
Of approximately 25 to... 35 millimeters. So... What we are going to do today is..
An echoendoscopy (endoscopic ultrasound [EUS]) with fine-needle aspiration... To allow us to obtain a diagnosis... A location... And the pathology... To enable us to understand... What we are... Looking at.
Whether we have a cancerous lesion... A benign lesion... An inflammatory lesion..
Or a neuroendocrine lesion. So.. The differential diagnosis is... Is significant here, and clearly... Makes this... An important procedure to perform.
We are just about to intubate the patient. We will use... Anesthesia... Monitored anesthesia.
Slowly placing the patient... In a lateral... Position. We will begin by intubating her... While we are... Ensuring that... The patient's airway is protected. She will need more sedation.
We are trying to have an... Endoscopic vision to... Avoid intubating..
Blindly. We are using a... Olympus endoscope... The GF-UCT180. This is a linear endoscope.
With the EXERA III system. The CLV-190... And the... Mash computer... 1995. This is the system that..
Appeared between the Aloka... Alpha 10 and F75. We will begin by intubating... We are attempting to bring up our endoscopic vision. Here... (Can we..
Bring down the lights, please). (Just a little, yes). At this moment, since we are... Sure we have reached the stomach... We will reduce... The amount of air we insufflate.
And attempt to... Use echoendoscopy... To have a... Vision of what we are... Looking for.
The first thing in order is... Locate the aorta... Which makes the basis of this echoendoscopy. This is the liver. We will turn 180 degrees.
We can see the aorta here. At this moment, it is important to attempt to... Find the celiac trunk. We will attempt to refine the image slightly. Here's the aorta... Joining the celiac trunk.
And we can observe the pancreas there... And the superior mesenteric artery. Here's the pancreas. This... This is different to what we observed... In the scan. These are cystic lesions.
The pancreatic duct... Seems to be dilated... With multiple, very dilated celiac lesions.
Perhaps this is a... Mucinous lesion.... Of the pancreatic duct. This is the main pancreatic duct... Seems very dilated. 9.4 millimeters. She will increase the depth. And perform..
An echo doppler. Color echo doppler... To ensure... Clearly the pancreatic duct is... Very dilated, with many branches..
Also dilated. So... There is a location... Near the end of the pancreas..
Around the tail... Where it is very difficult to differentiate both because they are all dilated. We can see dilation... The entire section... The junction between the body... And the tail of the pancreas. Everything is dilated. Every so often one wants to understand the..
Anatomy of the ducts... An MRI can be helpful. But the advantage of EUS here is... The ability to biopsy. There are criteria that will help us decide... If the patient is in need of surgery. They include symptomatic patients... Such as this..
Associated with a... Pancreatic duct... Of more than 8 (mm) in size..
Generally needs surgery. Other criteria... To determine if the patient needs surgery... Is the presence of nodules... Within the cystic lesions... As well as..
The presence of solid lesions... Because it is suggestive of... A cancerous lesion. Not simply precancerous..
But cancerous. Now Dr. Reem will attempt to move into... Into the duodenum to..
Analyse the head of the pancreas. And obtain more information. Only when our basis consists on what we have observed.
The symptoms... Dilated pancreatic duct... The presence of nodules... Within the cystic lesions... Only then do we have the criteria... To send this patient for surgery.
Here we can see the biliary duct... Moving through the head of the pancreas. There are also multiple cystic lesions... In the head of the pancreas. Many cystic lesions... In the head of the pancreas. Here's the portal vein..
Passing... In front of the confluence. We can see the gallbladder there. I like to drain the gallbladder. Only when it is necessary... And surgery is not a choice. It is not mandatory to perform a... Fine-needle aspiration here..
Because... We clearly have the diagnosis. We have dilation... We have cystic lesions... We have a pancreatic duct that is... Over 10 mm (in size). We have symptoms..
We have a patient with... A lesion ranging from the head to the tail. So... The diagnosis is, without question... An IPMN, clearly. But IPMN with... A characterization within... The cystic lesions..
That is very... Concerning. There are nodules... Some segments have a more solid appearance.
Unfortunately, this patient will need... A total pancreatectomy. Thank you. Thank you, Dr. Reem.
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