Internal Investigation

A sedated-but-awake middle-aged man lies on his side on a table in a dimly lit examining room. His work-boots-clad feet poke out from beneath a white sheet while gastroenterologist Manoop Bhutani slides a specialized endoscope through his esophagus into his stomach. Bhutani watches the scope's progress on a monitor mounted on a wall above the patient.

The patient complained of abdominal pain and has lost weight. A recent CT scan looked for signs of chronic pancreatitis-inflammation of the pancreas-but the results were inconclusive. Hoping to avoid surgery to find the source of the patient's symptoms, his doctors turned to Bhutani, a leading practitioner of endoscopic ultrasound.

Endoscopic ultrasound is a new technology that can help physicians decide between recommending surgery or less-invasive laparoscopic surgical procedures performed through small incisions. Bhutani is one of few experts in this field. He has written the first and only textbook about performing interventional procedures under endoscopic ultrasound guidance, and has trained three doctors-one from California, one from Egypt, and one from Brazil-through fellowship programs at UTMB. Since his arrival at UTMB in 2001, Bhutani has also traveled to Italy, Korea, and India to teach endoscopic ultrasound to the local physicians in these countries.

Bhutani steers the state-of-the-art endoscope toward the gastric wall of the patient's stomach. An ultrasonic probe fits on its tip, where fiber optics that transmit real-time images to a monitor are placed on traditional endoscopes. The lens is found on the side of this scope, just behind the ultrasonic probe, so Bhutani navigates by looking for landmarks on the walls of the patient's organs. "It's like driving a car while looking out the side window," he explains.

As Bhutani presses the ultrasonic probe against the stomach's gastric wall, the probe emits ultrasonic waves three millimeters beyond the stomach and produces an image of the pancreas on a second monitor mounted on the wall.

Bhutani's trained eye quickly identifies signs of scarring within the pancreas. He pauses at a dark shadow on the screen.

Bhutani zeroes in to observe the mass more closely and identify areas where cells should be collected for a biopsy. He then inserts a long, thin needle into a channel of the endoscope and guides it through the gastric wall into the pancreas. Bhutani steers the needle to the area he has marked on the screen and uses it to suck cells from the mass.

Meanwhile, a nurse phones the cytopathology division. As Bhutani draws the needle from the endoscope, a pathologist enters the room pushing a mini laboratory consisting of a microscope, glass slides, and jars of colored liquid.

If the cells are malignant, the patient will need surgery. If they aren't, Bhutani will recommend that the patient stop drinking alcohol and send him home. The inflammation in his pancreas will eventually go down.

The initial tests show that the patient does not have cancer. More comprehensive tests confirm those findings. Bhutani's patient is free not only of cancer but also of the surgical scars traditional methods would have entailed.
-Jennifer Reynolds-Sanchez