Endoscopic ultrasound at St. Joseph’s Health Care London first for academic centres in Ontario; one of few sites in Canada

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St. Joseph’s Health Care London is leading the way in Ontario with the introduction of endoscopic ultrasound, a technology that helps in the diagnosis and treatment of gastrointestinal diseases through a minimally invasive technique. It is currently available at only a few academic institutions across Canada. St. Joseph’s is the only academic institution to offer this technology presently in Ontario.

Dr. Nadeem Hussain performed his first such procedure at St. Joseph’s in early September, after training at the Medical University of South Carolina (MUSC) with Drs. Peter Cotton, Robert Hawes and Brenda Hoffman. The MUSC team is renowned as the pioneer of endoscopic ultrasound (EUS) in North America. MUSC is one of the few sites in North America offering such training opportunities.

“Endoscopic ultrasound, or EUS, involves the use of an endoscope (a flexible tube with a fiberoptic light and camera) attached with a miniature ultrasound machine (similar to those used to look at fetuses in the womb of pregnant women). This instrument can be inserted either through the mouth, or the anal canal. It not only allows the user to see the lining of the gastrointestinal tract (as conventional endoscopy does i.e., colonoscopy and gastroscopy) but also helps visualize the wall of the gastrointestinal tract as well as the adjacent structures (chest, liver, gallbladder, pancreas, bile system, spleen etc.). It allows the gastroenterologist to visualize beyond the wall of the gastrointestinal tract ‘simulating x-ray vision’,” says Hussain.

EUS has both diagnostic and therapeutic applications and is now often recommended as a standard of care in the staging of many gastrointestinal cancers and lung cancer. Staging helps to determine the extent of cancer tissue’s invasion into the body, which indicates how far advanced the cancer is. Its stage determines the appropriate treatment. “More accurate staging means the treatment, too, is more accurate,” says Hussain. In addition, EUS can be used to obtain tissue samples for pathological diagnosis of a suspected cancer.

“As a palliative treatment modality,” says Hussain, “EUS can deliver injections directly into nerves.” This is particularly important in alleviating pancreatic cancer pain, which is generally a very challenging symptom to manage. Ongoing research is looking at the potential to deliver treatments directly to the site of disease using EUS. This could be the delivery of treatment in the form of pellets of radiation, chemotherapy and potentially even gene therapy directly into tumors.

When compared to traditional ultrasound and other imaging technologies such as magnetic resonance imaging (MRI) and computed tomography (CT), EUS has several advantages: Because the endoscope is placed closer to the targeted tissue it can result in better images. “It also enables doctors to obtain tissue during the examination which improves its ability to be more accurate,” says Hussain.

“From the patient’s perspective, EUS can, in certain circumstances, be a less invasive method of arriving at a diagnosis allowing certain patients to forego unnecessary invasive surgery. It can also lessen their anxiety because some test results are available almost immediately following the procedure allowing for less waiting time.”

“For the health-care system, EUS could help reduce long waiting lists for CT and MRI, easing pressures on a hospital’s X-Ray department.”

EUS technology has been in development since the mid 1980s, but there have been many hurdles to overcome for it to become a standard of care. In Europe, it has been part of the mainstream medicine for over a decade. “But because the medical community is now seeing more scientific medical validation through research for its utility in clinical practice, EUS is slowly being incorporated into the diagnostic and treatment algorithm for many disease processes,” says Hussain.

One hurdle has been its cost – its price tag can be hefty, averaging anywhere from $0.5 – $1 million capital investment, not including the cost of supporting equipment. Another hurdle has been a manpower issue. The number of doctors trained to perform EUS is presently very small in North America. The small number of institutions with the technology, and physicians with the expertise, mean few opportunities for training additional practitioners. The next challenge is availability. A test is only as helpful as the number of people who can actually have access to it. To help it to become more universal, we need to train more physicians who are qualified to perform this test.

“One of the mandates of St. Joseph’s Health Care London is to become a leader in medical imaging. With the introduction of EUS as an imaging tool, St. Joseph’s is one step closer to meeting this objective. We are now able to offer our community what is considered state-of-the-art tool in imaging technology in North American and Europe.”

“This will be a resource not only for gastroenterologists,” says Dr. Richard Reynolds, Divisional Chief of Gastroenterology for UWO, “it will prove itself useful for oncologists, radiation oncologists, surgeons, various other internal medicine specialists and family physicians. We are anticipating referrals from across Southern Ontario.”