Pancreas: Standards and Innovations

Jacques DEVIERE, MD, PhDErasme University Hospital

Brussels – BelgiumJacques.deviere@erasme.ulb.ac.be

• Diagnosis• Stones, strictures• « Cysts », necrosectomy

Diagnosis: MRI and EUS haveERCP as standards

S-MRCP and Pancreas divisum

Normal response to stimulation

S0 S5 S10

Minor papilla dysfunction (25 y-old F)

baseline

Chronic pancreatitis earlystage/minimal changes

• N = 48• Normal CT • MRCP et ERCP

Se Sp PPV NPV Acc IA89 100 100 75 90 0.81

Matos et al, JOP 2004; 5: 48

S-MRCP vs SOM

SOM

Normal Abnormal Total

Normal 11 17 28

S-MRCP Abnormal 2 10 12

Total 13 27 40

Pereira SP, Gut 2007; 56:809

Insensitive in predicting abnormal manometry in type III SODUseful in selecting out patients with suspected SOD II

Costs considerationsPancreatic type II SOD

n=44

Testoni, 2004

13071703Costs for management / patient (€)

0.55 *1.66Procedure-relatedhospital stay (days)

48 %81 %

53 %69 %

Definite diagnosisEffectiveness at FUP

S-MRCP + targeted EPS

S-US + ERCP + Rx if necessary

s-MRCP and IPMT

S– S+S+

Duodenal duplication cyst• 17 y-old female, 3 episodes of acute pancreatitis / 8 months

Diffusion weighted imagingMRI gives PET-scan like opportunities

from Takeuchi et al. ECR 2007

DWI : Pancreatic cancer

DWI and autoimmune pancreatitis

Post Rxwith steroids

Severe Chronic Pancreatitis

ObtainedObtained afterafter a a medianmedian of 1 session of 1 session

withwith thethe highhigh power, Xpower, X--ray ray focusedfocused

machinesmachines

Guda NM, JOP 2005; 6: 6-12

ESWL/ET in the Management of Chronic Pancreatitis: A Meta-Analysis Effect on pain

balloon dilation4 mm x 4 cm

pancreaticstent

5 cm x 10F

Is pancreatic stenting needed life-long? Outcome after stent removal in 100 pts with CP

• Median duration of stenting : 23 months

• Median follow-up after stent removal : 27 months

→ 30% required restenting 5.5 (1-12) monthsafter removal

→ 70% pain free

Eleftheriadis et al, Endoscopy 2005

• Hospital admissions for pain treatment/y– before Rx : 1.98 ± 1.36– next 3 years : 0.40 ± 0.51– last 11 years : 0.14 ± 1.22

• Clinical success– no single hospital : 30%– <5/14 years : 35%

ESWL + endotherapy for CPA 14.5 years follow-up (56 patients)

Delhaye et al, Clin Gastr Hepatol 2004;2:1096-1106

Multiple Pancreatic Stenting

• Maximum 1 year stenting

• 18 (95%) “morphological stricture resolution”

• 16/18 (84%) pain free:mean follow-up 38 months (17-55)

Costamagna G et al, Endoscopy 2006

Endoscopic versus surgical therapyfor chronic pancreatitis

Dite et al, Endoscopy 2003;35:553-558

Endotherapy without ESWL

n=36

Surgery 80% resections/20% drainage

n=36

Mortality 0 0

Additional surgery 0 2 (6%)

Stenting duration (mo) 16 (12-27) 5 years follow-up

Complete pain relief 15% 33%*

Partial pain relief 46% 52%

Body weight increased 29% 47%*

Body weight unchanged 26% 25%

Diabetes 34% 39%

Endoscopic (n=19) versus surgical drainage (n=20) of the MPD in chronic pancreatitis

Cahen et al, NEJM 2007;356:676-684

Endoscopy

Surgery

Duration of symptoms (months) 16 ± 14 21 ± 19

Exocrine insufficiency 68% 80%

Median stenting 27 weeks (6-67)

Pain relief (24 months) : Complete 16% 40%

Partial 16% 35%

No relief 68% 25%

Conversion to surgery 4 (1 pain relief)

Hospital stay 8 11

Complications : Major 0 1

Minor 11 6

Mortality 1 0

Assessing treatments: ESWL alone in CP

Dumonceau et al, GUT 2007

ESWL with optional endoscopic treatmentvs ESWL and endotherapy

(CCP, no large pseudocyst, no biliary stenosis)

Dumonceau et al, Gut 2007;56:545-552

ESWL n=26

ESWL+endotherapy n=29

Initial RX (N) ERCPs 0 2 (1-4) ESWL 2 (1-3) 2 (1-4)

Hospital stay (days) 2 7*

Morbidity 0 1 (3%) Follow-up

Pain relapse at 2 years 10 (38%) 13 (45%) Whole (51 months) 11 (42%) 13 (45%)

Additional therapeutic procedures 8 (31%) 18 (62%)* ERCP 8 (31%) 18 (62%) ESWL 7 (27%) 7 (24%)

Surgery 1 (4%) 3 (11%) Hospital stay (days) 3.1 8.6

Cyst drainages - role of EUS

• Enlarged dramatically the indications to non bulging and/or distal collections.

• Decreased bleeding ? No RCT but...• Question less and less important since EUS

scopes now offer the same therapeuticcapabilities as duodenoscopes.

• Why still some non EUS guided drainages ?

International survey of ASGE memberspracticing EUS guided cyst drainage

Gastrointest Endosc 2006 ; 63 : 223-7

Characteristics US respondents

(n=103)

International respondents

(n=95)

Total respondents

(n=198)

p value

Mean no. Years in practice 11.5 17.5 14.4 <0.0001

Perform ERCP, no. (%) 102 (99) 94 (99) 196 (99) 0.9

EUS before transmural drainage of pseudocysts, no. (%)

72 (70) 56 (59) 128 (65) 0.1

EUS-guided drainage for transmural entry, no. (%)

58 (56) 41 (43) 99 (50)

0.06

Disconnected pancreatic tail syndrom:A model for multitechnical approach

EUS for cyst drainage - what did it change ?

Transpapillary

(n=15)

Without EUS

(n=28)

With EUS

(n=32)

Transpapillary +

Transmural

(N=41, 19 with EUS)

p value

Diameter, mm, median (IQR)

66.5 (50-95.5)

66 (40-99.8)

70 (44.3-90)

0.021

Bulging 25 (89.3) 12 (37.5) <0.0001

Distant 0 2 (6.3)

Tail 4 (26.7) 1 (3.6) 8 (25) 0.036

Complications, n (%) 0 3 (10.7) 3 (9.4) 7 (17.1) 0.331

Technical success, n (%) 14 (93.3) 29 (96.4) 30 (93.8) 37 (90.2) 0.8

Clinical success, n (%) 14 (93.3) 25 (89.3) 29 (90.6) 34 (82.9) 0.65

Hookey et al, Gastrointestinal Endoscopy 2006

Pancreatic duct leakageRoad map before and after therapy

Extending our way to notesInfected necrosis (gastric bypass)

Voermans et al,GI Endosc 2007

Transmural debridement ofsymptomatic pancreatic necrosis

• 27 collections in 25 patients.• Median stay : 5 days.• Clinical success : 93%.• Major complications : 2 (arterial

bleeding and cyst wall perforation requiring surgery).

• No mortality.

Voermans et al, GIE 2007 ; 66 : 909

Endoscopic therapy for pancreaticnecrosis and abscesses

• 13 patients.• Immediate surgery avoided in 11

patients.• Delayed elective surgery in 2

patients.

Seewald et al, GIE 2005 ; 62 : 92

When the collection has been drained (necrosis), only a fistula remains

Fistula tract opacified

Arvanitakis et al, AJG 2007

Catheter loaded with a guidewire is positioned in the paraduodenal virtual PFC,which is identified by EUS after water/contrast injection

EUS-guided transmural drainage of the virtual cavity and insertion of a double pig-tail stent

Conclusion

Percutaneous

MRIEUS

ERCP

Performed by the same teamand available « when needed »With surgeons on a daily basis

GEEWJune 22-24, 2009

Brussels

www.live-endoscopy.com