We herein describe endoscopic treatment of symptomatic pancreatic pseudocyst with significant necrosis and a fistula. Fifty eight year old man had presented to us with a large pseudocyst following an episode of acute pancreatitis. He was complaining of significant abdominal pain for two months. A... CT scan abdominal had revealed a large retro-gastric pseudocyst with necrosis and portal venous thrombosis. An upper GI endoscopy had revealed small linear fundal varcies. Endoscopic as well as surgical treatment for the cyst was discussed with the patient. Patient wished not to undergo surgical treatment and therefore endoscopic treatment was selected after a proper consent. EUS was performed to see for the interposed vessel prior to the pseudocyst puncture. Needle knife puncture was made and a guide wire was passed in the pseudocyst cavity. After confirming the wire placement in the cyst, the tract was dilated up to 20 mms using a CRE balloon. Fluid from the cyst was emptied out in the stomach. An ERCP scope was passed in to the cyst cavity, which revealed a significant necrotic material (much more than what the CT scan had revealed). All the free lying necrotic material was taken out with the help of a snare and a dormia basket. A lot of necrotic was stuck to the cyst wall, which was removed with the help of water jet, mechanical scooping and cutting through using a needle knife papillotome. Three 10 fr. Pigtail stents were placed at the end of the procedure. Further necrosectomy was carried out on alternate days for three more sessions. Dilation was required prior to each session three pigtail trans-gastric stents were placed at the end of each session. Single stent was kept in situ during each procedure to guide the path (the position of the stoma changed dramatically once the cyst was empty). During the last lesion (session four), a pancreatogram was taken. It revealed a mildly dilated CBD in the head, normally duct in the proximal body with a leak from the distal body, and contrast was seen going in to the pseudocyst cavity. The duct could not be opacified distally. A 7 fr. 15 cms stent was placed trans-papillary. When the cyst cavity was reentered through trans-gastric route, the trans-papillary pancreatic stent was clearly visible with soft necrotic material around it. In fact, the stent guided further necrosis removal. It also helped in diverting the pancreatic juice to the duodenum rather than in the pseudocyst cavity. Patient was discharged after this session and was followed up regularly. A CT scan was obtained after three months, which revealed a complete resolution of the necrosis and pseudocyst. There was a possibility of a persistent fistula after the removal of trans-papillary stent and a recurrence of the pseudocyst. Fistula closure with cyanoacrylate glue is well described in the literature. The procedure can have obvious complications secondary to accidental blockage of the main pancreatic duct. So, we thought it prudent to use a safer alternative to treat the condition. We removed the longer pancreatic stent and replaced it with a shorter pancreatic stent occupying only the head region. The patient was followed up after a month; sonography of the abdomen did not reveal any recurrence of the pseudocyst. All the stents were removed at this examination.

On screening colonoscopy, this abnormality was encountered in the cecum. This round worm is Ascaris Lumbricoides, one of the most common human parasites in the world. When ingested, the durable Ascaris eggs hatch in the small intestine releasing larva that migrate through the intestinal wall, and t...ravel both hematogenously and lymphatically to the heart and lungs. Over the next several days, the larva mature in the alveoli, then migrate up the trachea to be swallowed back into the gastrointestinal tract. These larva will then mature in the small bowel; adults couples will succeed in producing an extraordinary number of eggs, over 200,000 ova per day. The adults live one to two years. The majority of Ascaris infections are as in this example asymptomatic. Symptoms are a consequence of either the immunologic hypersensitivity of the host to the worm as in the pulmonary stage referred as Loffler's syndrome or to mechanical obstruction of lumen by the worm. Heavy worm burden can result in intestinal obstruction and migrating worms can cause pancreatitis and/or cholangitis when involving the pancreatobiliary tree. Multiple medical therapies are approved for its treatment including mebendazole. Epidemiologically, infections are most common in areas of lower socio-economic conditions. This man manages a pig farm in China that is used to test pharmaceutical agents. From an endoscopic standpoint it is noteworthy that the worms do not like light and will move away fro the attention it is receiving. In this example, the endoscopist was too slow to snare his prey which succeeded in escaping temporarily into the cooler and darker confines of the small bowel out of reach of the endoscope but not from the soon to be consumed anti-helminthic therapy.

Access to processes within the skull base with lateral extension to the pterygopalatine fossa are reached by combined subfrontal osteotomy and Le Fort I osteotomy

This video shows how to draw a blood sample which is medically known as venepuncture

Trabeculectomy surgery

TRAM only in cases where a Diep or Gracilis is not applicable

teeth crowns

Arestin Antibiotic for Periodontal Disease

cardiac catheterization in the work up of heart disease.

This is an amazing device designed to transport body organs and blood long distances. The inventor of this life-saving device is Randal Miller.

Osteochondral Allograft

Laser Liposuction for Weight Loss

Re-educating the legs to walk again is the ultimate goal of this therapy for those who have suffered a stroke. ~ Detroit Medical Center

DMC Pediatric Heart Specialist Doctor Peter Karpawich is the first in the state to use minimally invasive surgery to repair a damaged pacemaker on a pediatric patient, helping her lead a more active, fulfilling lifestyle. ~ Detroit Medical Center

DMC Interventional Radiologist Doctor Bruce Wolf uses minimally invasive surgery called Balloon Kyphoplasty to bring relief to a patient suffering from severe back pain caused by spinal compression fractures. This new procedure is especially beneficial to patients suffering from osteoporosis. ~ Detroit Medical Center

DMC's Surgical Simulation Lab creates a virtual anatomy, allowing surgeons to train and enhance their skill before moving to live patients. ~ Detroit Medical Center

Preparing the Syringe for Injection

A UK patient praises Dr.Venkatachalam for her Hip resurfacing surgery. She was able to get full movements after surgery which wouldn't have been possible with a hip replacement

Radial Artery Catheterization

A discussion and demonstration of suturing techniques with Lee Dresang, MD from the University of Wisconsin Department of Family Medicine