Endotherapy of chronic pancreatitisDr Chirayu Chokshi

EUS –MRCP OR BOTH OF THEM?

SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC PATIENT WITH WT LOSS

ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF

MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

DIAGNOSIS

HIGHLY SENSITIVE

POOR SPECIFICITYWITHOUT

BX

91-100% EUS FNA :LOW RISK OF SEEDLING

OPERATOR DEPENDENTNOT AVAILABLE

ENDOSONOGRAPHY

EUS

DETECTION OF DEBRIS IN COLLECTIONCHANGES OF EARLY CHRONIC/CHRONIC PANCREATITISRULE OUT PSEDOANEURYSMWALL VESSELS AND SELECTION OF SITEr/o mass in pancreas

Endo. Treatment for chr pancreatitis,timing,duration and type of inteVrention Thai Nguyen-Tang,Jean Marc Dumonceau.2010 Clinical Gastroenterology.

EUS, MRCP OR BOTH ?

MRCP

MPD ANATOMY ESP.DOMINANT DUCTAL STRICTURE,MPD OBSTACLERUPTURE OF MPD COMMUNICATION WITH COLLECTION

ERCP ?

IF MRCP NOT CONCLUSIVE/NOT DONE BEFORE DRAINAGE OF COLLECTION THOUGH SOMETIMES DIFFICULT

EUS, MRCP OR BOTH ?

Endo. Treatment for chr pancreatitis,timing,duration and type of intevention Thai Nguyen-Tang,Jean Marc Dumonceau.2010 Clinical Gastroenterology.

EUS –MRCP OR BOTH OF THEM?

SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC PATIENT WITH WT LOSS

ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF

MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

2007

CHRONIC PANCREATITIS:ASIA PACIFIC CONSENSUS REPORT:J OF GASTRO AND HEPATO.2002:17.508-518R TANDON,P GARG,NOBUHIRO SATO

PEARLS:

1.Successful TRIAL OF ENDOSCOPIC TREATMENT BEFORE SURGERY

2.DILATED DUCTAL SYSTEM AND FAILED MEDIAL AND ENDOSCOPIC TREATMENT

3.CANCER SUSPICION

4.PSEUDOCYST NOT AMENABLE TO ENDOSCOPIC TREATMENT

WHEN SURGERY

Pain in chronic pancreatitis:

Surgical options: MPD

DILATED DUCT NON DILATED

RESECTION- DISTAL PANCREATECTOMY HEAD RESECTIONDRAINAGE

FOCAL INFLAMM.MASS

ABSENTPRESENT

RESECTION +DRAINAGE

SURGERY : STANDARD ,TIME TESTED TREATMENT

RESULTS OF SURGERY:

VARIABLEPATIENT SELECTION

TYPE AND EXTENT OF SURGERYVARIABLE F/UP

SPONT.PAIN RELIEF AFTER DZ BURNOUT

WHY ENDOSCOPIC TRAETMENT? LESS INVASIVESHORT RESULTS COMPARABLE TO

SXPREDICTS OUTCOME AFTER SXSX ALWAYS POSSIBLE AFTER

FAILED ENDOTHERAPY

BEST CANDIDATE FOR ENDOSCOPIC TREATMENT:

STRICTURE IN PANCREATIC HEAD WITH ‘UPSTREAM DILATATION’

Cremer deveiere.Stenting in CP:Results of long term fup of 76 pts.ENDOSCOPy 1991:23:171-176

AUTHOR YR NO STENT F/UP EARLY PAIN RELIEF SUST.RELIEF OPERATED %

Cremer 1991 75 10 37 94% na 15Ponchon 1995 23 10 14 74% 52 15Smits 1995 49 10 34 82% 82% 6Binmoeller1995 93 5/7/10 58 74% 65% 26Morgan 2003 25 5/7/8.5 na 65% na naVitale 2004 89 5/7/10 43 83% 68% 12Eleftheriades ‘05 100 8.5/10 69 70% 62% 4%Ishiara 2006 20 10 21 95% 90% naWeber 2007 17 all 24 89% 83% na

Plastic stents for MPD strictures:

Large pancreatic stents are commonly used

After definitive stent removal , 27-38% have pain relapse in 2.1-3.8 yrs

Pain relapse treated with stenting

Short term pain relief 70-94% Long term pain relief 52-82%

EUS –MRCP OR BOTH OF THEM?

SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC PATIENT WITH WT LOSS

ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF

MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

ERCP FOR PAIN IN CHRONIC PANCREATITIS

PANCREATIC SPHINCTEROTOMY

RELIEF OF DUCTAL OBSTRUCTION

MINOR PAPILLA DRAINAGE IN P.DIVISIUM

STRICTURE DILATATION

REMOVAL OF OBSTRUCTED DUCTAL STONES

BALLOON/BOUGIE/STENTS

ESWL/MECH.LITHO

EUS GUIDED :PANCREATICOGASTROSTOMYPANCREATICODUODENOSTOMYCOELIAC AXIS BLOCK

Endotherapy of pancreatic stones:

DormiaBaloon extarctionMech litho.ESWLBalloon sphincteroplasty of papilla

Large stonesStone above stricture

VIDEO COURTESY BY DR V RATHOD

MPD DRAINAGE SHOULD BE PLANNED EARLY IN COURSE OF CALCIFYING CP

Duomoneauque jm,j deviere Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones.long term results.GIEndoscopy 1996:43:547-55Binmoeller ,soehendra Endoscopic pancreatic drainage in CP and a dominant stricture .ENDOSCOPY 1995:27;638-44Rosch T,Daniel,Huibregtse Endoscopic rx of CP:multicenter study of 1000 pts.ENDOSCOPY 2000:34;765-71

STONES 18%STRICTURES 47% STONE AND STRICTURE 32%

51% HAD NO PAIN IN 4.9 YRS

Pancreatic stone management :

Small , 5mm non calcific stones can be removed with ERCP

Farnbacher ,Schoen schneider.Pancraetic stone ductal in chr pancreatitis.Criteria for treatment intensity and success.GIEndoscopy 20012:56:501-6

70-90% stones cannot be extracted without pre ERCP fragmentation

J Deveriare .GIEndoscopy 1996:43:547-55

ESWL: First line mx

COMPLETE PAIN RELIEF IN 62% VS 55% after 2yrsCostamagna et al Treatment for painful calcified chronic pancreatitis”ESWLv/s endoscopic Rx:RCTGUT2007:56:545-7Ohara Takeuchi et al Single application eswl is the first choice in CCP.AmJgastr 1996:91:1388-94

for pain in calcifying CP

ESWL alone or ERCP combined should be done

early in course of painful CPDelahaye,J Deveiere Long term clinical outcome in painful CP after endoscopic pancreatic ductal drainageClininc gastr hepatology 2004:2:1096

Take home message:

EUS –MRCP OR BOTH OF THEM?

SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC PATIENT WITH WT LOSS

ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF

MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

DEFINITIONS OF PANCREATIC FLUID COLLECTION

CHRONIC PSEUDOCYST:

COLLECTION OF PANCREATIC JUICE ENCLOSED BY WALL OF FIBROUS OR GRANULATION TISSUE DUE TO CHRONIC PANCREATITIS

INCIDENCE OF PSEUDOCYST AFTER AC PANCREATITIS 5-16% CHR PANCREATITS 20-40%

BRADLEY EL A CLINICALLY BASED CLASSIFICATION SYSTEM FOR AC PANCREATITIS.SUMMARY OF INTERNL SYMP ON AC PANCREATTIS 1992ARCH SURG 1993:128:586-590BARTHET M BUGALLO M MX OF CYSTS AND PSEUDOCYSTS COMPLICATING CHR PNCREATITIS,A RETRO STUDY 143 PTS.GASTROENTEROLOGY CLINC BBIOL 1993: 17- 2770-276ELLIOT PANCREATIC PSEUDOCYSTS SURG CLINIC OF N AMERICA 1975:55-339-362

CHRONIC PSEUDOCYSTS DUE TO ALCOHOL64%

ALCOHOL RELATED PANCRETIC PSEUDOCYSTS 56%-78%

AETIOLOGY OF PANCREATITIS:GALL STONE 6-36%POST TRAUMATIC OR SURGICAL 3-8%IDIOPATHIC 6-20%

SANFEY H JONES PSEUDOCYSTS OF PANCREAS ,A REVIEW OF 143 CASES AM SURG 1994:60:661-668LAWSON LC FROMKES ERCP IN MX OF PANC PSEUDOCSTS AM J SURG 1985-:150:683-686USATOFF V OPERATIVE TREATMENT OF PSEUDOPCYSTS IN CHRONIC PANCREATITIS BR J SURG 2000 :87-1494-1499KOLARS JC PANCREATIC PSEUDOCYSTS ARCH SURG 1990 125:759-763

CT SCAN IS MANDATORY

FOR PLANNING

THERAPY OF PANCREATIC PSEUDOCYST

SENSITIVITY 82%-100%SPECIFICITY 92-94%OVERALL ACCURACY 88-94%

HAWES RH ENDOSCOPIC MANAGEMENT OF PSEUDOCYSTT.Rev Gastroenterolo Disord 2003 :3;135-141LEE STALEY PANCREATIC IMAGING BY US/CT SCAN Radiological clinicof N A 1979:17:105-117

MX OPTIONS: ENDOSCOPIC RX:

Create an alternative correct duct disruptionCYSTOENTERAL drainage route

TRANSMURAL DRAINAGE TRANSPAPILLARY DRAINAGE

GIE 2009 2004 1999.CURRENT TRENDS IN GASTROENTEROLOGY 2002

CT SCAN

PORTAL HT NO PORTAL HT

NO DIGESTIVE BULGE DIGESTIVE BULGE

EUS GUIDED PROCEDURE TRANSPAPILLARY DRAINAGE TRANSMURAL DRAINAGE

LARGE CYST >= 5 CM CYST <5 CMSNO PD COMMUNICATION PD COMMUNICATION

BARTHET etal Clinical usefullnesss of the a treatment algorithm f or pancreatic pseudocystG I ENDOSCOPY 2008:VOL 67;245-52

Prospective series of 50 pts :endoscopic drainage possible in 98% pts and collection dissapearence in 98% cases with a f/up of 11 months

COMPLICATED PANCREATIC PSEUDOCYSTS [1 CRITERION SUFFICENT]

COMPRESSION OF LARGE VESSELS[CLINICAL SYMTOMSOR ON CT SCAN] GASTRIC OR DUODENAL OBSTRUCTIONSTENOSIS OF THE CBDINFECTED PSEUDOCYSTH’GE INTO PSEUDO CYTSPANCRETICOPLEURAL FISTULA

INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTS

SYMTOMATIC PANCREATIC PSEUDOCYSTSSATIETYPAIN N AUSEA VOMITINGUPPER G I BLEED

ASYMTOMATIC PANCREATIC PSEUDOCYSTDIAMETER MORE THAN 4 CMS AND EXTRAPANCREATIC COMLN IN PTS WITH CHRONIC ALCOHOLIC PANCREATITISPSEUDOCYTS MORE THAN 5 CMS-UNCHANGED MORPHOLOGY FOR MORE THAN 6 WKS

INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTS

DISTANCE OF PSEUDOCYST TO THE GUT WALL LESS THAN 1 CM

LOCATION OF TRANSMURAL APPROACH BASED ON MAXIMUM BULGE OF THE PSEUDOCYST TO THE ADJACENT WALL

PREREQUISITE FOR ENDOSCOPIC DRAINAGE

Rossea e ,Pancreatic Pseudocyst in Chronic pancreatitis.endoscopic and surgical treatment Dig surg 2003:20:397-406Monkemuller ,kahl.Endoscopic therapy of chronic pancreatitis. Dig dz 2004:22:280-291Smiths ME,Rauws Tytgat .The efficacy of endoscopic treatment of pancreatic pseudocysts. Gastrointestinal endoscopy 1995:42-202-207Monkemuller KE Baron Morgan.Transmural Drainage of pancreatic fluid collection using seldinger technique.Gastrointestinal Endoscopy 1998:48:195-200

6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS

Pseudocyst drainage by gastroscope

6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS

ENDOSCOPIC DRAINAGE :COMPLICATIONS 5-16% MORE IN CASE OF NECROSIS

BLEEDING: 8-10% -PSEUDOANEURYSM - GASTRIC DUODENAL VESSEL RUPTURE - ENLARGED COLLATERALS- INFECTION:less than 5% in clear pseudocysts Retroperitoneal perforation Stent migration Stent induced ductal changes

J GISURGERY 2008,PANCREAS 2008,GIE 2004

Single MPD stoneSingle stricture in MPDSingle stone and strictureEarly Pancreas divisium Pseudocyst with clear contents or minimal debris

Take home message: endoscopic treatment only when

Endoscopic pancreatic necrosectomy:

Limited in its use in centres of expertise that deal with pancreatic necrosis day in and outInsufficient data to recommend a particular technique

Though included in 10-15 guidelines,,,level of evidence supporting recommendationis not included

WJS loveday BP 2009

Can is definitely not should !!!