Complex Cases

Advances in technology have made endoscopic procedures a “minimally invasive” option highly effective in diagnosing and treating diseases of the digestive tract. Here are some case studies to illustrate of the use of such advanced techniques. All procedures were performed by the author.

Bile duct stricture after gallbladder surgery

A 50-year old woman had surgery in her home country to remove her gallbladder. After operation, she developed two areas of narrowing (or strictures) in her bile ducts [arrows, A]. She suffered intermittent fevers, chills and abdomen pain. Two plastic tubes (or stents) were inserted at ERCP but failed to resolve her problem. The patient was referred for further treatment. ERCP was performed to stretch (or dilate) the narrowed areas with a balloon [B]. This was followed by insertion of 4 plastic stents [C] to maintain the size of the bile ducts. The stents were changed twice over a one-year period with a successful outcome. The strictures were widened [arrows, D] and she did not suffer further symptoms. Stents are effective treatment for 90% of patients suffering from post-operative strictures.

Duodenum obstruction due to advanced pancreas cancer

A 48-year old man had advanced pancreas cancer that involved the duodenum resulting in obstruction. He could not eat and had to be fed intravenously. A combined gastroscopy and X-ray procedure was performed to insert a self-expandable metal stent through the obstruction [ellipse, E, F] using a guide-wire. The metal stent [G] was released and expanded 24 hours later to its maximum diameter [H]. This allowed the patient some improvement in his quality of life before he succumbed to the cancer.

Bile duct leak after liver transplantation

A 50-year old man with end-stage liver cirrhosis due to hepatitis B received a living donor liver transplant from his son. After surgery he developed a bile leak that did not resolve and an attempt at ERCP stenting was made. The bile leak did not resolve after the first ERCP and he was referred for further treatment. The bile leak was identified at the level of the anastomosis (or surgical joint) [ellipse, I] between the donor and recipient bile ducts. Two plastic stents were successfully inserted across the leak which stopped completely [J]. A few months later, the stents were removed [K]. The patient is doing well 2 years after the transplant.

About the author. Dr Yap Chin Kong, is a leading Specialist and Senior Consultant in Gastroenterology, Liver Diseases and Endoscopy. He was awarded a Merit Scholarship to study Medicine at the National University of Singapore and graduated with a Bachelor of Medicine & Bachelor of Surgery degree in 1983. In 1988 he obtained his Masters degree in Medicine (Singapore) and became a Member of the Royal College of Physicians (United Kingdom). He became a Fellow of the Academy of Medicine (Singapore) in 1994 and a Fellow of the Royal College of Physicians (Edinburgh) in 2000. In 1992, he was awarded the Health Manpower Development Program Award by the Ministry of Health to pursue advanced training in therapeutic ERCP (Endoscopic Retrograde Cholangio-Pancreatography) at the Academic Medical Centre in Amsterdam, The Netherlands. After a year of extensive experience he returned in 1993 to develop endoscopy further at the Singapore General Hospital until he left for private practice in 2004. He pioneered the use of endoscopic ltrasonography at SGH for a decade. During this time, he taught many generations of medical students and post-graduate doctors. In 2002, he continued to pursue his interest in early cancers of the stomach and colon and visited the Showa University Hospital in Yokohama, and the National Cancer Centre in Tsukiji, Tokyo. He lectured and taught at workshops locally and internationally, combining the best of Western and Eastern techniques. A Master endoscopist, he developed an innovative cap-fitted gastroscopy technique that is used to help countless patients worldwide. He was President of the Gastroenterological Society of Singapore (1999 to 2003) and was President of the Asia-Pacific Digestive Week in 2003. He is currently in private practice at Mount Elizabeth Medical Centre. His broad specialist experience include advanced endoscopy techniques such as ERCP treatment of bile duct stones and pancreas diseases, endoscopic ultrasound, treatment of esophagus, stomach, colon and liver cancers, viral hepatitis and inflammatory bowel disease. He is Visiting Consultant to the National University Hospital and Kandang Kerbau Womens’ & Childrens’ Hospital where he supervises gastroenterologists-in-training and performs endoscopy for sick children.