Crossing borders

Priya A. Jamidar, M.B.Ch.B., has seen a great deal of the world. After a childhood spent between Kenya, India and the United Kingdom, Jamidar received his medical degree in Belfast, and completed his residency and fellowships in Connecticut, California and Indiana before settling down in Yale’s Section of Digestive Diseases in 2004.

But it is the inner world of the human body that has most captivated Jamidar, who says he aspired to a medical career as early as he can remember. An associate professor of medicine, Jamidar is an expert practitioner of endoscopic retrograde cholangiopancreatography, or ERCP, a technique in which a long, flexible tube inserted through the mouth is used to diagnose and treat disorders of the ducts that drain the gallbladder, pancreas and liver.

In his diagnostic work, Jamidar, guided by video monitors and by lights in the ERCP scope, threads the probe through the esophagus, stomach and small intestine and injects contrast dye into ducts to make X-rays of gallstones, duct blockages or cancer. For pancreatitis or undiagnosed cases of abdominal pain, Jamidar uses the scope to insert a tiny catheter that measures pressure in the sphincter of Oddi, a muscle that controls the flow of bile and pancreatic fluid into the small intestine. If a patient has gallstones trapped in their bile ducts, Jamidar uses a basket or balloon passed through the scope to remove the stones whole, or shatters them with an electrically generated shock wave. In patients with sphincter of Oddi hypertension, he uses the probe to make a small incision to loosen the sphincter, which gives two-thirds of patients relief from their symptoms, he says.

“The therapeutic aspect of ERCP has made a lot of surgery unnecessary,” says Jamidar, and he has been spreading the word in a series of workshops for local physicians. In these sessions, doctors seated in a conference room observe actual ERCP procedures via real-time video feeds and interact with Jamidar using two-way microphones. Jamidar hopes that seeing the benefits of the technique first-hand will help physicians improve their skills and will encourage them to refer their more complicated cases to the Yale Medical Group’s burgeoning ERCP practice, which now performs more than 700 ERCP procedures per year.

“ERCP has a long learning curve, and it does carry significant risks in less-experienced hands,” Jamidar says. “We strongly believe in communicating well with gastroenterologists in the community, who tend to refer cases that have either failed elsewhere or are of a level of complexity that they need to be done at a center of excellence like Yale.”

Jamidar says that “the line between medicine and surgery has become quite blurred” by techniques like ERCP. “I’ve always loved working with my hands, and I wanted to be a surgeon at one point. But I decided to practice gastroenterology instead. ERCP comes pretty close to surgery in many ways.”

During an upcoming sabbatical, Jamidar plans to move even closer to surgery under the tutelage of Paul Swain, M.D., of the Royal London Hospital, one of the leading lights in an emerging subspecialty known as natural orifice transluminal endoscopic surgery, or NOTES. Swain, who gained fame as one of the inventors of the PillCam, a capsule-sized camera that patients can swallow to capture images of the digestive tract, has recently created an endoscopic sewing machine that will allow doctors like Jamidar to suture incisions made with instruments inserted through the mouth.

Jamidar looks forward to exploring the possibilities of NOTES at Yale. “In the future we’ll have people who will draw from both surgery and gastroenterology who will be able to do a lot of things for patients without going to the operating room,” he says. “I think it’s going to be for everyone’s good.”