Live endoscopy session demonstrated advanced diagnostic and therapeutic techniques for complex pancreaticobiliary and colorectal cases, including repeat POEM for achalasia recurrence, underwater endoscopic intramuscular dissection for rectal cancer, and cholangioscopy-guided management of an intraductal biliary mass.
- For a 5mm pancreatic body lesion with indeterminate features on contrast-enhanced EUS and DFI, the speakers recommended surveillance MRI in 3 months rather than biopsy, as the procedure should only be performed if it changes management; most audience members agreed not to puncture such a small lesion.
- In ERCP for multiple impacted CBD stones with esophageal stricture, the team performed limited sphincterotomy followed by 12mm large balloon dilation and sequential balloon extraction, successfully clearing stones using a long-wire technique and avoiding stent placement.
- A repeat POEM procedure was performed posteriorly for achalasia type one with persistent dysphagia after prior anterior POEM; the speaker stated approximately 10 percent of patients develop recurrence after one year and emphasized cutting only the circular muscle layer with a myotomy of at least 4cm starting 7cm above the cardia.
- For a 2 to 3cm flat depressed rectal cancer with no lymph node involvement, the speakers advocated endoscopic intramuscular dissection rather than standard ESD, citing recent data published in Gut showing this approach suitable for selected low-risk patients to achieve deeper resection margins while avoiding the 2.5mm submucosal invasion limitation of conventional ESD.
- A 12mm CBD mass with internal vascularity on superb microvascular imaging and soft elastography was managed conservatively without EUS-guided biopsy due to seeding concerns raised by surgeons; the team planned ERCP with cholangioscopy and intraductal biopsies as the diagnostic approach, with adenoma as the leading differential diagnosis.
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