A fistula is a tract or connection between two organs, such as the stomach and the skin, the esophagus and lung or the colon and the urinary bladder, to name a few. With recent advances in endoscopy—such as endoscopic suturing, closure devices and stents—most of these procedures can be performed on an outpatient basis.

This procedure is used for treating problems stemming from the small bowel. Doctors use a long endoscope, equipped with two inflatable balloons that manipulate the small bowel, to take tissue samples, stop a bleed, enlarge a stricture or retrieve a swallowed object. With this device, the clear majority of the 20-foot-long small intestine can be visually inspected, and patients benefit from a thorough exam. Cedars-Sinai was 1 of 6 original centers that pioneered this incredible procedure to examine the small intestine.

This therapy is most often used to relieve pain and improve how pancreatic ducts drain. It is used in patients with severe biliary pancreatitis, pancreatic duct disruptions, strictures (narrowing of a passage) and pancreatic stones. This type of procedure is very delicate and requires highly skilled and expertly trained interventional gastroenterologists. The Pancreatic & Biliary and Interventional Gastroenterology programs at Cedars Sinai are among the very few offering this pancreatic procedure.

ERCP is used to remove or open obstructions in the gallbladder or bile ducts, repair complications from previous surgeries, and to reach pancreatic or bile duct tumors for biopsy. Cedars-Sinai is one of a few centers in the U.S. that also performs ERCP procedures in patients who have had the gastrointestinal tract altered by prior surgeries.

While this is not an endoscopic procedure, it is commonly performed in conjunction with ERCP to relieve pancreatic duct blockage caused by stones. ESWL is most commonly done to break down kidney stones. However, Cedars-Sinai is one of a small number of medical centers in the U.S. that is able to expertly use this form of shockwave to shatter the stones that cause severe pain and chronic scarring of the pancreas.

Myotomy is defined as cutting a piece of muscle. Patients suffering from permanently spastic tissue or muscle in the gastrointestinal tract that leads to difficulty swallowing or digesting food may be offered this procedure. By leveraging specialists that can carefully perform a myotomy, patients can regain the ability to enjoy food and drastically improve their quality of life. Some well-known myotomy procedures performed at Cedars-Sinai are:

• Per-oral endoscopic myotomy (POEM): This is one of the most innovative procedures used to treat a very difficult swallowing problem caused by the esophageal sphincter failing to relax. Since the problem comes from the muscle of the esophagus, this procedure is done by inserting an endoscope into the middle layer of the wall of the esophagus. This tunneling technique creates a long, hollow tract from the middle of the esophagus down to the gastroesophageal sphincter or valve and into the beginning of the stomach. This tract makes it very easy to see the rubber band-like rings of muscle. By cutting through these muscles, the tightness of the sphincter is able to relax, allowing most patients to swallow again.
• Zenker's myotomy: Zenker's diverticulum is a pocket-like pouch in the very top of the esophagus. It forms because of muscle spasm of the cricopharyngeal muscle—a pocket in the back of the esophagus—which collects food that comes down from the mouth. This results in trouble swallowing, regurgitation of food, and may put patients at risk for aspiration or inhaling food into the airways. Aspiration is very dangerous and causes breathing problems, obstruction to the airway and/or an infection in the lungs. The endoscopic treatment is done by splitting the center part of this pocket, allowing food or water to pass through the central slit without retaining the food.

The treatment for inflammation of the gallbladder, commonly known as acute cholecystitis, can require surgery. Occasionally, patients are too high-risk for surgery and thus nonoperative drainage is necessary. This has been traditionally performed by interventional radiology. With recent advancements in endoscopic technology, doctors can now perform endoscopic drainage to treat these high-risk patients. This can be performed as an ERCP or by placing a temporary stent connecting the inflamed gallbladder to the stomach or duodenum to allow drainage.

Severe inflammation of the pancreas can lead to pancreatic tissue necrosis. This has traditionally required surgery to remove the dead tissue. With recent advances in the field, doctors at Cedars-Sinai can remove the tissue via endoscopy without the need for surgery. This procedure may require a few sessions in an outpatient procedure setting.

Traditionally, a large, flat tumor, even at a benign stage, must be removed by open or laparoscopic surgery. Today, doctors are able to remove these lesions, whether benign or cancerous, with 1 of the following methods:

• Mucosectomy: Also called an endoscopic mucosal resection, this procedure uses an endoscope to remove lesions or superficial tumors from the moist tissue layer (mucosa) of the gastrointestinal tract. Very flat dysplastic tissue—Barrett's esophagus or large colon polyps—typically requires mucosectomy for complete removal. Since this procedure strips the superficial level of the colon, small intestine or esophagus, highly skilled endoscopists are needed to ensure that complications are minimized.
• Submucosal dissection (ESD): This is a highly specialized endoscopic procedure used to remove early tumors and cancers that have not grown deep into the muscle layer of the gastrointestinal tract, such as from the esophagus, stomach and rectum, without the need for surgery. Often, this can be curative for early-stage cancers. The procedure requires specialized endoscopic training and state-of-the-art endoscopic equipment. It has been commonly used in Asia to remove early gastric cancer, but is relatively new to the U.S. The Cedars-Sinai Interventional Gastroenterology Program is one of a few in the country to provide this treatment to patients.

A stent is a small, expandable device that is implanted to hold tissue in place, keep a vessel open or provide support to a weakened area. Endoscopic stenting is often performed to keep pancreatic and biliary ducts open. Occasionally the gastrointestinal tract opens in cases of obstruction from a tumor or from benign conditions. These can be temporary or permanent, depending on the condition.

Long-term acid reflux can result in a change in the lining of the esophagus called Barrett's esophagus. This is a premalignant lesion that may increase the risk for a type of cancer called esophageal adenocarcinoma. With the rapid development of endoscopic technology over the past 2 decades, safe and effective treatments are available for dysplasia and early cancer. Other treatments include endoscopic mucosal resection, radiofrequency ablation and cryotherapy.

Gastric varices are dilated veins in the stomach that can cause significant bleeding. They develop mostly because of liver cirrhosis and occasionally from clotting of certain veins, such as the splenic vein, because of pancreatitis. Our team is one of the few centers who treat these conditions with the endoscope, specialized coils and glue injection.

The obesity epidemic in the U.S. has grown exponentially across every age, race, gender and socioeconomic group. Health risks related to obesity are well established, as are the benefits of weight loss. Despite the widespread knowledge about the effectiveness of bariatric surgery, only 1-2% of qualified patients receive bariatric surgery because of limited access, irreversibility of the surgery, associated risks and high costs.

• Bariatric and metabolic diseases: With the advent of new and exciting endoscopic devices and tools, coupled with a multidisciplinary approach, Cedars-Sinai offers safer and noninvasive ways to help patients lose their excess weight. The bariatric and metabolic support team comprises expert, board-certified interventional gastroenterologists, as well as clinical dietitians specializing in nutritional support. Together, patients, their families and a multidisciplinary team can discuss the risks and benefits of all the options and develop a personalized weight-loss plan.   
• Management of post-bariatric surgery complications: Post-bariatric complications can include a surgical leak, stenosis, bleeding, ulcers or weight regain. Surgical revision may be unavoidable in some situations; however, it is associated with high morbidity and mortality, despite a skilled surgical team. The interventional gastroenterologists at Cedars-Sinai manage these post-surgical complications using noninvasive endoscopic tools including stents, suturing, clips and ablative methods.  
  
• Endoscopic sleeve gastroplasty: Endoscopic sleeve gastroplasty is a revolutionary procedure designed to mimic the weight loss you expect from a traditional sleeve gastrectomy, without the need for surgery. The procedure is done completely through the mouth, by endoscopy and endoscopic suturing, to reduce the size and the volume of the stomach. Unlike the surgical counterpart, this procedure is reversible and repeatable, if necessary. Endoscopic sleeve gastroplasty is a safe, effective alternative for patients who are not ideal surgical candidates or who prefer a nonsurgical option. On average, patients lost about 60 pounds within 6 months of the procedure without any significant adverse effects.   
  
• Transoral Outlet Reduction (TORe) Procedure: Roux-en-Y gastric bypass (RYGB) surgery continues to be a very popular and effective means of losing weight. Unfortunately, up to 60% of patients who undergo RYGB experience significant weight regain with detrimental effect on their quality of life. Surgical revision options are available but are associated with high complication rates. The TORe procedure is completely incisionless, done through the mouth by endoscopy and endoscopic suturing to reduce the size of the stomach pouch and the outlet. It is a safe procedure that has been proven to be very effective in helping patients lose weight that has been regained. On average, patients lose about 20 pounds of the weight they regained since the previous surgery.