New Approach To Treating Pancreatic Disease - Medical Frontiers

Key Concepts

• Endoscopic Ultrasound (EU): A medical imaging technique that combines endoscopy with ultrasound to visualize internal organs.
• Pancreas: An organ in the digestive system that produces digestive enzymes and hormones like insulin.
• Pancreatic Cancer: A malignant tumor of the pancreas, often diagnosed late due to its silent nature.
• Pancreatitis: Inflammation of the pancreas, which can be acute or chronic.
• Pancreatic Duct: The tube that carries pancreatic juice from the pancreas to the duodenum.
• Stent: A tube inserted into a duct or blood vessel to keep it open.
• Gastroenterostomy Bypass: A surgical procedure to create a new pathway for food from the stomach to the small intestine.
• IT Stent: A self-developed stent by Ittoy for draining pancreatic juice.
• EPASS (EU-guided Gastroenterostomy Bypass): A minimally invasive procedure for creating a gastroenterostomy bypass using EU.

Early Detection of Pancreatic Diseases with Endoscopic Ultrasound (EU)

Diseases of the pancreas, particularly pancreatic cancer, are notoriously difficult to detect early. Statistics highlight this challenge: only 7.8% of pancreatic cancer cases are discovered at stage 1, with nearly half of patients diagnosed at the advanced stage 4. The pancreas is often referred to as a "silent organ" due to the lack of early symptoms and its deep anatomical location, making traditional diagnostic methods like abdominal ultrasound, CT, and MRI less effective for early detection.

Endoscopic Ultrasound (EU) offers a significant advancement. This procedure involves inserting an endoscope equipped with an ultrasound device through the mouth. By positioning the ultrasound transducer inside the body, closer to the pancreas, EU can generate highly detailed, real-time images, revealing even small abnormalities that might be missed by external imaging techniques.

Comparison with Traditional Imaging:

• CT/MRI: Valuable for providing an overall view of the pancreas in relation to surrounding organs and blood vessels.
• EU: Capable of detecting subtle abnormalities, such as a 6 mm tumor that was not visible on a CT scan.

The EU scope, approximately 1.2 meters long and 14 mm in diameter, features a camera, light, and an ultrasound device at its tip. It is guided through the stomach and duodenum to achieve optimal proximity to the pancreas.

EU for Diagnosis and Biopsy

When EU identifies a suspicious lesion, such as a tumor, the scope can be fitted with a needle. This allows doctors to perform a fine-needle aspiration (FNA) to collect cells for detailed pathological analysis, crucial for determining if the abnormality is cancerous.

The Role and Function of the Pancreas

The pancreas plays two vital roles:

1. Digestive Function: It produces pancreatic juice, a potent digestive fluid that flows into the duodenum to break down food.
2. Endocrine Function: It produces hormones, such as insulin, that regulate blood sugar and digestive secretions, which are transported through the bloodstream.

Increasing Incidence and Survival Rates

Cases of acute and chronic pancreatitis, as well as pancreatic cancer, are on the rise, partly attributed to dietary changes that strain the organ. Pancreatic cancer incidence has increased nearly eight-fold over the past 40 years. The later the diagnosis, the lower the survival rate. A Japanese survey indicated a mere 1.6% 5-year survival rate for patients diagnosed at stage 4. EU is a key tool being utilized globally to improve early detection.

Case Study: Kato Yasco's Early Diagnosis

Kato Yasco was diagnosed with stage 1 pancreatic cancer in March 2025. An MRI performed for another condition incidentally revealed a suspicious change in her pancreas, prompting a referral for EU. EU imaging showed a slight narrowing in the pancreatic duct, a black tube-like structure. Further examination of her pancreatic juice confirmed stage 1 pancreatic cancer. She underwent surgery in May 2025, where half of her pancreas was removed, and the cancer was completely excised. She is currently undergoing oral anti-cancer drug treatment to prevent recurrence.

EU in Pancreatic Disease Treatment

EU is increasingly being used not only for diagnosis but also for treatment.

Treatment of Chronic Pancreatitis with the IT Stent

Chronic pancreatitis, characterized by long-term inflammation leading to pancreatic hardening and impaired function, is a significant risk factor for pancreatic cancer (over 10-fold increase). Blockages or narrowing in the pancreatic duct disrupt the flow of pancreatic juice, causing pain due to pressure buildup.

In a case involving a large stone blocking the pancreatic duct near its exit, conventional stenting proved impossible. Ittoy, a leading EU specialist, employed EU to insert a stent from the stomach, creating a new drainage route for pancreatic juice.

Procedure:

1. The EU scope was advanced into the stomach.
2. A needle was inserted into the pancreatic duct.
3. The duct was widened.
4. A specially developed "IT stent" was placed. This stent has a straight end and a pig's tail-like curled end. The curled end anchors securely in the stomach, creating a stable passage for pancreatic juice to drain into the stomach, alleviating symptoms.

The IT stent, developed by Ittoy, has been in use in Japan since 2015 and is adopted by many hospitals. This EU-guided approach significantly reduced the strain on the patient compared to open surgery.

EU-Guided Gastroenterostomy Bypass (EPASS) for Advanced Pancreatic Cancer

For patients with advanced pancreatic cancer causing gastric obstruction and narrowing of the duodenum, eating becomes difficult. The EPASS procedure, developed by Ittoy and his team, offers a minimally invasive solution.

Procedure:

1. The EU scope is inserted into the stomach.
2. Two balloons are inserted into the jejunum (a part of the small intestine).
3. The balloons are inflated, and the space between them is filled with blue-dyed water, which is clearly visible on ultrasound.
4. The EU scope identifies the optimal site for the bypass.
5. An electric current is used to create openings in the stomach and jejunum.
6. A stent is placed to connect the stomach to the jejunum, creating a new pathway for food.

This procedure, which takes approximately 15 minutes, allows patients to eat again, helping them maintain strength and continue chemotherapy. As of 2025, EPASS is offered at Ittoy's hospital, with efforts underway for wider adoption.

Expert Perspectives and Mentorship

Robert Haw, former president of the American Society for Gastrointestinal Endoscopies, highlights the importance of sharing Ittoy's techniques to help more patients. He commends Ittoy's inquisitive nature, dedication to developing younger physicians, and positive outlook.

Risk Factors and Warning Signs for Pancreatic Diseases

Ittoy outlines seven risk factors for pancreatic diseases:

1. Daily alcohol consumption for over 10 years.
2. Preference for fatty foods.
3. Obesity.
4. Lack of exercise.
5. Smoking.
6. Stress (work or personal relationships).
7. Diabetes.

He also lists eight warning signs that warrant immediate medical attention:

1. Loss of appetite.
2. Weight loss.
3. Abdominal bloating.
4. Persistent indigestion or heartburn.
5. Pain in the upper abdomen or back.
6. Diarrhea or whitish stools.
7. Jaundice.
8. Worsening of diabetes.

It is emphasized that even a single sign should prompt a doctor's visit.

Conclusion

The video underscores the transformative impact of Endoscopic Ultrasound (EU) in the early diagnosis and treatment of pancreatic diseases. The dedication of pioneers like Ittoy, coupled with technological advancements, is significantly improving patient outcomes, offering hope for conditions that were once considered largely untreatable in their early stages. The emphasis on risk factor awareness and prompt medical attention for warning signs is crucial for proactive pancreatic health management.