Endoscopy Asia’s Approach for Lower G.I. Bleeding

A 64 yrs female patient was referred to Endoscopy Asia for the favor of Ileo-Colonoscopy to evaluate the exact etiology of frank bleeding per rectum.

Endoscopy Asia’s Intervention:

• Diagnosis: Since Patient gave history of two episodes in last 2 days, we considered her for the procedure after a thorough preparation. Ileo-colonoscopy revealed a small 3-4 mm classical Angiodysplastic lesion in the caecum close to the appendicular opening. The lesion was very well appreciated on NBI (narrow band imaging). Terminal ileum (15 cms) and rest of the colon appeared absolutely normal.

• Treatment: In view of the above findings, bipolar heater probe coagulation was performed and the lesion was completely fulgurated. Complete haemostasis was ensured and patient was sent home on OPD basis.

• Prognosis of the patient: The patient responded very well to the treatment.

Important Note from Endoscopy Asia

It is our protocol at Endoscopy Asia that whenever a patient is subjected for colonoscopy, we always make an attempt to have inspection of terminal ileum in all patients, more so if we are suspecting any bleeding lesions. It is important to have all therapeutic options available as we know there are mechanical and thermal methods of haemostasis. Here we felt that bipolar heater probe coagulation was effective and it provides complete fulguration of the lesion, however, one has be cautious as the wall of caecum is thinnest compared to other parts of the colon. Optimal bowel preparation is the key.

1.Classical angiodysplasia seen in caecum

2. Angiodysplasia seen on NBI in caecum

3.The lesion was fulgurated with bipolar heater probe

4. Post fulguration complete haemostasis achieved

Large Pancreatic Pseudocyst treated quickly with Endoscopy

Ajay Singh, 45 year old male patient came to Endoscopy Asia with pain in abdomen since one and half months. He complained of loss of appetite and weight. On physical examination, a large lump was felt on the abdomen.

Past Medical History of patient revealed that the patient had severe pancreatic inflammation one year back, for which he was operated through a large midline incision. Patient subsequently developed hernia at the incision site for which was again operated upon.

Patient had gone through several imaging studies (CT scan-abdomen, USG-Abdomen) which revealed a large fluid filled sac behind the stomach. Patient consulted several surgeons for the treatment, but they were reluctant to operate in view of history of multiple surgeries in the past.

Endoscopy Asia’s Intervention

• Diagnosis: Patient was evaluated with endoscopic ultrasound and the size of the fluid collection was determined as 14 cm X 11 cm. On colour Doppler it was confirmed that it is not connected to any vascular structure. A diagnosis of Large Pancreatic Pseudocyst was reached upon.
• Treatment: Patient was operated by Endoscopy to drain the fluid collection. The procedure was done in twenty minutes without any complications and almost 2 litres of fluid was drained. 
• Prognosis of the patient: The patient’s symptoms were revealed within three hours of the procedure. He resumed work after three days of surgery.

The case became complicated due to multiple scars of previous surgeries, resultant intra-abdominal adhesions and large size of the fluid.  Endoscopic Ultrasound guided Endoscopic cystogastrostomy performed at Endoscopy Asia has been the standard practice at the centre since last 13 years. The safety of the procedures performed at Endoscopy Asia is ensured due to vast experience and expertise of the doctors at the centre.

Photographs of the procedure:

Unilocular Pancreatic pseudocyst

Double pigtail 10fr stent in situ

Fluoroscopy showing 10fr stent in situ

Endoscopy Asia successfully treats a patient suffering from pancreatic stones

Patient Aarti Bhagat, 17 years old, was referred to Endoscopy Asia with severe abdominal pain and vomiting. Patient’s past history revealed of multiple hospitalizations due to recurrent attacks of severe abdominal pain since 5 years.  After undergoing several imaging modalities like CT scan abdomen, Ultrasonography and MRI, no accurate diagnosis could be reached nor could any treatment procedure be outlined.

Endoscopy Asia’s Intervention:

• Diagnosis:  Endoscopy Asia considered opting for Endoscopic Ultrasound (EUS) as the best method to evaluate the pancreato-biliary system. EUS revealed large soft stones in the dilated pancreatic duct (14 mm) which was the cause of recurrent acute-on-chronic pancreatitis. Finally, an accurate diagnosis was arrived for patient’s  symptoms. Patient was diagnosed with Advanced chronic calculus pancreatitis (Stone in the pancreas leading to Inflammation of pancreas).

• Treatment:  Endoscopy Asia decided to perform ERCP (Endoscopic Retrograde Cholangio Pancreatography) whereby all the stones were cleared from the pancreatic duct.

• Prognosis of the patient: Post procedure patient did not complain of pain, vomiting or any other symptoms and no further attacks of pancreatitis were observed. 

EUS performed at Endoscopy Asia can provide high-resolution images of both the ductal structures and parenchyma of the pancreas. Therefore it has the maximum sensitivity and specificity for the diagnosis of pancreatic diseases. Treatment of pancreatitis and pancreatic stone disease provided at Endoscopy Asia provides adequate relief from the symptoms without any invasive surgical intervention. Recent studies have also shown that pancreatic exocrine function can improve after the endoscopic treatment. 

Eus Picture Showing Dilated Pancreatic Duct With Stones Within	Pancreatogram Showing Filling Defects In Main Pancreatic Duct Suggestive Of Stones
Pancreatic Duct Clearance Revealing Soft Stones	Pancreatic Duct Stenting Showing Free Flow Of Pancreatic Juice

Phenomenal Response to Live Webinar on Advanced Therapeutic Endoscopy

Another landmark Live Webinar on Advanced Therapeutic Endoscopy organized by Dr Rathod Medical Foundation in association with Endoscopy Asia on 21st September, 2013 which was sixth in the series, received phenomenal response from India as well as all over the world. More than 1500 participants saw the live streaming of Post-radiotherapy Esophageal stricture dilatation being performed by Dr. Vipulroy Rathod.  The Webinar offered important insights on:

1. Post-radiotherapy Esophageal stricture dilatation
2. Endoscopic Ultrasound staging for carcinoma esophagus
3. Treatment of Common bile duct stone
4. Endoscopic  ultrasound  of pancreatico-biliary system for chronic recurrent  pancreatitis  with jaundice
5. Endoscopic excision of  gastric submucosal polyp
6. Endoscopic resection of giant esophageal tumor

Dr. Vipuroy Rathod demonstrated how to perform the above procedures while avoiding the possible complications of perforations & bleeding. The participants came from 40 centres across India including both Government and Private Hospital doctors, each center having almost 40 to 50 doctors glued to their laptops and mobiles. There was live interaction between Gastroenterologist from USA, UK, Middle East and our neighboring countries. Besides, Gastroenterologists, Endoscopists, Surgeons, MD Physicians and DM/DNB fellows who attended the Webinar there were also Gynecologists who had addressed their doubts about  the management of pancreatitis and cholecystitis in pregnancy. During the Live Surgery, the participants found the approach of Dr. Rathod very insightful.

Dr. Vipulroy Rathod’s Guidelines for the case:

1. During the Esophageal balloon dilatation there may be the perforation during the procedure  so dilatation should be the gradual and during the dilatation put an eye on the pulse rate.
2. EUS staging is the standard for all the esophageal cancer for planning treatment strategy
3. For all biliary pathology prior to ERCP, EUS must be done to predict the possible complications during the procedure. Sphinchterotomy should be meticulously controlled. Prior preparation for control of possible bleeding like saline-adrenaline injections should be ready. Post ERCP complication rate in our setup is less than 1% , where as the complication rate in all the other leading centres in India and abroad range from 10-15%.
4. EUS is performed in all cases of pancreatitis to determine the current status and its etiology and plan further management. Unlike other imaging studies, EUS gives information regarding both the ductal and parenchymal pathology.
5. Prior EUS determines the exact location and vascularity of the lesion that help to plan the procedure. Loop ligation of the polypoidal lesion strangulates the lesion and obviates the chance of bleeding from the stump.

There were various doubts and questions raised by the participating doctors which Dr. Rathod  answered at length like the preferred position for ERCP, what should be the length of CBD stent, how to manage a condition where pancreatic duct stent migrated to spleen and then to pleural cavity, etc.

The Webinar ended with gratitude from the participants. Dr. Hemant Sant and Baroda Surgeons Association found the webinar as an excellent flawless demonstration of an endoscopic procedure and heartily congratulated Dr. Rathod. Dr. Siddesh made it a point to regularly attend the webinars conducted by Dr. Rathod.

 
The Live webinar proved pivotal in addressing the issues related to practicing efficient Endoscopy procedures across the globe. It was an important milestone in creating awareness and spreading quality healthcare practices within the society.

Dr Rathod Medical Foundation – Making ourselves available to people who cannot afford quality medical care

Endoscopy Asia’s CSR activities are executed under the umbrella of Dr Rathod’s Medical Foundation, named after his father, Dr Dayanand Hargovindas Rathod(FRCS). Endoscopy Asia extends its philanthropic approach to all the needy and underprivileged patients to have access to a world class service through its philanthropic partner Dr Rathod Medical Foundation irrespective of patient affordability. Nobody is deprived of world class healthcare and that these services are made available to all who require it.

At Endoscopy Asia, 40% of the work done is highly subsidized and for some even free through the Foundation, irrespective of patient affordability. Nobody is deprived of world class healthcare and that these services are made available to all who require it.

The Foundation is also actively involved in providing regular Basic & Advanced Endoscopy Training Courses to all aspiring Gastroenterologist, Endoscopist, Surgeons and Physicians from USA, UK, Canada, Europe, Malaysia, Singapore, Thailand, Indonesia, Australia, Philipines, Syria, UAE, Oman, Iran, Libya, Sri Lanka, Pakistan, Bangladesh, Myanmar, Nepal, Russia and South Africa. He has trained more than 70 International Fellow Gastroenterologists and more than 340 Indian Consultants in Advanced Diagnostic and Therapeutic Endoscopy, ERCP & EUS procedures. 

Dr Rathod addressing doctors who come for fellowship at Endoscopy Asia	Endoscopy Asia organizing a live Webinar to a group of doctors

The Foundation in collaboration with Endoscopy Asia also conducts regular CME (Continued Medical Education) for Family Physicians and General Practitioners to update them on the latest techniques in diagnosis and treatment protocols available in Endoscopy & Gastroenterology.

Dr Rathod Medical Foundation also encourages regular Fellowship Programs and provides a stipend for young doctors who want to learn and further train in the field of Gastroenterology and Endoscopy.

Endoscopy Guru – Teaching is empowering, teaching is revolutionizing & teaching is a Tradition

At Endoscopy Asia, over the past few years, Dr Rathod has conducted over 8 hands-on well structured courses in Endoscopy. The last course in December 2012 brought together the International pioneering masters in the field of Endoscopy namely Dr. Laurent Palazzo from France, Dr. Peter Vilmann from Denmark and Dr. Haruhiro Inoue from Japan. We even had some eminent personalities in the field of Gastroenterology and Endoscopy from across India such as Dr. D Nageshwar Reddy, Dr. T Chandrashekhar, Dr. Rakesh Kochar, Dr. Mahesh Goenka, Dr. Matthew Philip, and Dr. Randhir Sud gracing our event as faculty. Also, there were more than 20 local Gastroenterologists from Mumbai itself who actively assisted Dr. Vipulroy Rathod throughout the Conference. This course also saw the launch of India's first online educational portal in gastroenterology called "Endoscopy Guru" through which he conducts free live webinars and classes for doctors across the world to educate them in timely diagnosis and treatment.

Dr Vipulroy Rathod addressing the New channels	Dr Laurent Palazzo talking to news channels
Dr Peter Vilmann talking about the conference	Dr Haruhiro Inoue on pioneering POEM procedure

Dr Peter Vilmann at his best at Endoscopy Asia	Dr H Inoue performing POEM on a 11yr old girl who suffered from Achalasia Cardia, at Endoscopy Asia
Dr Vikram Bhatia teaching a fellow participant the finer nuances of Endoscopy	Dr Rathod addressing a group of participant during the Hand on session on wet models

The International, National and Local Faculties with Dr Vipulroy Rathod at our December 2012 Conference on Advance and Therapeutic Endoscopy at Mumbai

Director – Experience & Perseverence speaks for itself

Vipulroy Dayanand Rathod is a Gastroenterologist and Endoscopist (born on May 13, 1964 in Navsari, Gujarat, India). He is the founder and director of Endoscopy Asia. Vipulroy Rathod has been in clinical practice in Mumbai for more than a decade and has the largest individual experience in Advanced Endoscopy and Endoscopic ultrasound in the Indian subcontinent and is the pioneer of Interventional Pancreato-Billiary EUS.

After completing his M.B.B.S at Veer Narmad South Gujarat University in Gujarat, India in 1988 and his M.S in General Surgery in 1992, he went to Germany as a clinical fellow and trainee in Advanced Therapeutic Endoscopy and Endosonography at the Department of Endoscopic Surgery of University Medical Center Hamburg-Eppendorf, Germany under Prof. Nib Sohendra and Dr. Kenneth Binmoeller . In 1998, He performed the first ever Interventional Endosonographic procedure in India and pioneered Diagnostic and Interventional Endosonographic Ultrasound in this part of the world.

He has performed more than 17,000 EUS procedures in the last decade (2002-2013) including more than 7500 Interventional EUS procedures, which is the largest individual experience of EUS in India and this part of the world, apart from over 20,000 various diagnostic and therapeutic endoscopic procedures and ERCP.

Dr. Rathod is the promoter and director of Endoscopy Asia, a state of the art tertiary care facility in Gastroenterology, Hepatology & Endoscopy, located at Sion, Mumbai. His vast experience in Advanced Therapeutic ERCP has complimented his EUS skills in diagnosis, for desired clinical outcomes. He has found the role of combined approach of Endoscopic Ultrasound (EUS) and ERCP to be of great value in patients with acute, recurrent acute and chronic pancreatitis apart from pancreatic tumors.

Through Endoscopy Asia, Dr. Rathod Medical Foundation and Endoscopy Guru, Dr. Rathod has trained over 350 aspiring Gastroenterologists and Endoscopists from around the world. He has trained more than 75 International Fellow Gasteroenterologists from as far as USA, UK, Malaysia, Singapore, Thailand, Indonesia, Australia, Philippines, Slovakia, Syria, UAE, Oman, Iran, Libya, Sri Lanka, Pakistan, Bangladesh, Myanmar, Nepal, Russia and South Africa.

He is recognized as one of the world leaders in Endoscopic ultrasound and has represented India in over 50 countries as International Faculty, Speaker and Demonstrator in leading Gastroenterology & Endoscopy conferences and workshops. In 2006, he was invited as a visiting professor at Yale University, New Haven USA. He has been awarded a fellowship as Fellow of American Society of Gastrointestinal Endoscopy (FASGE).

Dr. Rathod is in high regard in the Indian society and is respected as an exemplary role model for the youth in his field. 

Achievements – What it takes to be one of the best

Qualifications

• 1988- M.B.B.S. South Gujarat University
• 1992- M.S. (Gen. Surgery)
• 1993- Certificate of Proficiency in Laparoscopic surgery from Dr. Mohan Chellappa, Singapore
• 1994- Observer ship under Dr. David Theobald
• 1995 Certificate of preceptorship in Diagnostic and Therapeutic Endoscopy from Dr. Cheng Jun ,Singapore General Hospital and Mount Elizabeth Hospital, Singapore)
• 1996- Certificate of Proficiency in Gastrointestinal Surgery, Diagnostic and Therapeutic Endoscopic procedures and Laparoscopic surgery from Dr. Anand Nande at Shrikhande clinic and Bombay Hospital
• 1996-1997- Clinical Fellow and Trainee in Advanced Therapeutic Endoscopy & Endosonography, Department of Endoscopic Surgery, University Hospital, Hamburg, Germany

Experience

• Attached to Endoscopy & EUS Department, Bhatia, Jaslok, Lilavati & BSES MG Hospitals, India
• Consultant in Endoscopy & EUS Department
• Has provided training to more than 100 Indian Consultants in last 7 years in various fields of G.I. Endoscopy, ERCP and EUS
• Has trained more than 20 International trainees in Advanced ERCP & EUS procedures

Awards & Affiliations

• Founder Member of Indian Association of Gastrointestinal Endo-Surgeons
• International Hepatico-Pancreatico-Biliary Association (Indian Chapter)
• Endoscopic and Laparoscopic Surgeons of Asia (ELSA, Hongkong)
• International Member of ASGE (American Society of Gastrointestinal Endoscopy)
• Life Member of Society of Gastrointestinal Endoscopy of India (SGEI)

Papers, Presentation & Research

• More than 15 papers presented in various National and International conferences since 1996 related to Endoscopic Surgery
• More than 500  lectures delivered across the country in National and International Conferences since 1998
• Participated as a Invited Faculty at more than 50 National & International workshops on Therapeutic Endoscopy since 1998
• Has co-organized more than 10 conferences on Gastroenterology and Endoscopy in last 8 years as Course Director and Course Co-coordinator
• Has been invited as a Visiting Professor at various academic institutions in India & Abroad
• More than 25 articles and abstracts published in National & International Journals of Endoscopy
• Reviewer for Journal Gastroenterology & Hepatology
• Has performed more than 7000 therapeutic endoscopic procedures that includes Therapeutic Upper G.I. Endoscopic procedures, Colonoscopic procedures & Advanced Therapeutic ERCP procedures
• Has the largest individual series of Endoscopic Ultrasound (EUS) procedures in India & this part of Asia
• More than 1000 Interventional EUS procedures performed in last 6 years that comprises of:

• EUS guided FNA of the Mediastinal masses & Lymphnodes
• EUS guided FNA of the Pancreatic & Gall bladder Lesions
• EUS guided Pseudocyst drainage & stenting
• EUS guided Coeliac Axis Neurolysis

International Invitations & Presentations:

• Invited as a Visiting Professor at University of Santo Thomas, Manila, Philippines in November 2000 for live demonstration of EUS procedures
• Visiting Professor to deliver a talk at Changi General Hospital, Singapore under the auspices of Singapore Gastroenterology Society in May 2001
• Invited as an International Faculty to Demostrate EUS and deliver a talk at the Latin American Society of Endoscopy Meeting, at Hospital De Caracas, Venezuela in March 2002
• Invited as an International Faculty at the 1st Egyptian Digestive Disease Week to Demonstrate Endoscopic & EUS Procedures and deliver a talk- March 2002
• Presented two abstracts on Endoscopy & Endoscopic Ultrasound at the Digestive Disease Week, San Francisco, May 2002, of which one was selected as Poster of Distinctions and was discussed in grand rounds
• Invited as a Guest Speaker at the University of Wisconsin Medical College, Milwaukee, USA- May 2002 to deliver a lecture on EUS experience of India
• Three abstracts accepted for presentation at the 13th International Symposium on EUS at New York, 3-5 October, 2002
• Co-authored a review article in Gastrointestinal Endoscopy October 2002 issue on Difficult Pancreatic mass FNA- Technical tips of success
• Invited as International Faculty for The Annual Gastroenterology Conference of New Zealand, Auckland, November, 2002
• Invited as an International Faculty for The Inaugral HepatoBiliary Masterclass meet at Colombo South Teachning Hospital, Srilanka- March 2003
• Invited as Faculty for the APDW Singapore 2003 for live demonstration in Endoscopy Workshop September 2003
• Invited as a visiting Professor to deliver lectures on Advanced Endoscopy & Endosonography at Yangon and Mandalay, Myanmar December 2003
• Invited as International Faculty for the Update on Gastroenterology, Hepatology and Endoscopy held at Muscat, Oman in April 2004, to deliver talks and perform live endoscopic procedures in the workshop
• Invited for a Video lecture at Advanced Endoscopy Update organized by the Medical University of South Carolina, Charleston in May 2004
• Invited as an International Faculty for a dedicated Endosonography Workshop at Tehran, Iran, June 2004
• Invited as a Speaker at the 14th International EUS Symposium held at Tokyo, Japan, November, 2004
• Invited to deliver a lecture at The National University Hospital, Gastroenterology Department, December, 2004
• Invited as an International Faculty at The 4th Iranian International Congress of Gastroenterology & Hepatology to deliver lectures on Advanced ERCP and Endosonography and also to perform live procedures in the workshop, December, 2004
• Invited as an Instructor and Faculty for the Endoscopic Ultrasound Workshop held at University of Malaya Hospital, Organized by the The Malaysian Society of Gastroenterology & Hepatology. Jan 2005
• Invited as Guest faculty to perform live procedures in the dedicated Endoscopic Ultrasound Workshop at Pondok Indah Hospital, Jakarta, Indonesia, February 2005
• Invited as an International Faculty at The 21st Annual Congress of Gastroenterology & G.I. Endoscopy, Peshawar, Pakistan, March 2005
• Invited as International Faculty to deliver lectures at The 3rd European Congress of Endoscopic Ultrasound Scanning- Copenhagen- June 2005
• Organized the 1st International Symposium On EUS at Mumbai with live workshop and hands on training on animate lab- August, 2005, Mumbai, India
•  Invited as an International Faculty at The World Congress of Gastroenterology EUS Course to be held at Montreal, Canada, September, 2005
• Invited as International Faculty at The U.K. EUS Users Group Conference to be held at Cambridge, November, 2005
• Invited as a Visiting Professor to The Hamad Medical Corporation for a talk and live demonstration of Endoscopic and Endosonographic procedures December 2005
• Invited as an International Faculty at Sharjah for a talk on Endosonography at the Middle East & African Gastroenterology Annual Conference Feb 2006
• Invited as a Visiting Professor at Yale University, New Haven USA to deliver a talk on Endosonography, May 2006
• Invited for a lecture at Orlando in May 2006
• Invited as an International Faculty at the Annual Gastroenterology Conference at Slovakia in September 2006