Best of UEG week 2017

(Pancreas-biliary)

Marianna Arvanitakis

Erasme University Hospital, ULB, Brussels, Belgium

10th Nottingham Endoscopy Masterclass

SPEAKER DECLARATIONS

This presenter has the following

declarations of relationship with industry

• NONE

[28/10/17]

3

OP103: COVERED VS UNCOVERED SEMS FOR

PALLIATION IN MALIGNANT CBD STRICTURES: A RCT

4Mangiavillano et al, UEG journal 5S, A44

Clin Gastrol Hepatol 2013

Latest meta-analysis of 9 RCTs (1061 patients)

No difference in stent patency, AP, cholecystitis, cholangitis, perforation, LoS

Covered SEMS: More stent migration (OR 7.1)

More tumor overgrowth (OR 1.9)

Less tumor ingrowth (OR 0.2)

ESGE guidelines 2012

OP103: COVERED VS UNCOVERED SEMS FOR

PALLIATION IN MALIGNANT CBD STRICTURES: A RCT

5Mangiavillano et al, UEG journal 5S, A44

FC SEMS

NitiS Biliary

N=78

Uncovered SEMS

NitiS Biliary

N=78

RCT: Primary end-point Stent patency

Secondary end-point AE

148/156 analysed

Technical success 98.7% 100% NS

Decrease in bili -70% -68% NS

Normalisation in bili 28.2% 28.9% NS

AE 25.4% 13.1% 0.09

Migration 7% 0% 0.024

Stent patency 9.5 mo 18 mo 0.046

OP107: DIGITAL SOC FOR TREATMENT OF DIFFICULT

STONES

6

International, multicenter, retrospective study

407 patients with difficult bile stones (2/15-2/16)

D-SOC with laser lithotripsy or electro-hydraulic lithotripsy

Difficult stones: large (15mm), multiple, impacted,

cystic/IH duct, Mirizzi syndrome, biliary stricture

Failed ERCP before treatment: 85.8%

End points:

Technical success

Safety

Brewer-Guttierez et al, UEG journal 5S, A45

OP107: DIGITAL SOC FOR TREATMENT OF DIFFICULT

STONES

7Brewer-Guttierez et al, UEG journal 5S, A45

Total

(n=407)

EHL

(n=306)

LL

(n=101)

P

Technical success 396 (97.3%) 296 (96.7%) 100 (99%) NS

Number of

sessions (med)

1(1-4) 1 (1-4) 1 (1-4) NS

Need for ESWL or

surgery

1 1 0 NS

Duration of

procedure (min)

67 73 49 <0.001

OP105: SHORT TYPE DBE FOR ERCP: A LARGE CASE SERIES

8Shimatani et al, UEG journal 5S, A44

Usefulness of new short DBE for ERCP on post-

operative patients

Retrospective study with 222 post-operative

patients (280 procedures)

End points:

Success rate and time for reaching the blind end

Diagnostic success rate

Therapeutic success rate

Overall success rate

Mean time to complete DB-ERCP

Adverse effects

OP105: SHORT TYPE DBE FOR ERCP: A LARGE CASE SERIES

9Shimatani et al, UEG journal 5S, A44

RnY HJ WhippleRnY total gastrectomy

91

pt

42

pt

85

pt

RnY HJ RnY total Whipple Total

Success blind end 95.6% 100% 100% 98.6%

Time blind end (min) 20.9 13.4 8.4/20 14.4

Success diagnostic rate 100% 95.2% 98% 97.4%

Overall success rate DB-

ERCP

95.6% 95.2% 98% 96.1%

Time for DB-ERCP (min) 71.7 78.5 42 61

AE 1.1%

OP106: EUS GUIDED GASTRO-GASTROSTOMY ASSISTED

ERCP VS ENTEROSCOPY ASSISTED ERCP IN RNYGB

10Bukhari et al, UEG journal 5S, A45

Multicenter, comparative trial

Kedia et al, GIE 2015

OP106: EUS GUIDED GASTRO-GASTROSTOMY ASSISTED

ERCP VS ENTEROSCOPY ASSISTED ERCP IN RNYGB

11Bukhari et al, UEG journal 5S, A45

160 patients, 5 centers

12

OP359:INTRADUCTAL ABLATION DURING ENDOSCOPIC

AMPULLECTOMY

Perez-Cuadrado et al, UEG journal 5S, A152

Retrospective analysis of patients undergoing endoscopic

ampullectomy

Rustagi et al, GIE 2016

13

OP359:INTRADUCTAL ABLATION DURING ENDOSCOPIC

AMPULLECTOMY

Perez-Cuadrado et al, UEG journal 5S, A152

Retrospective analysis of patients undergoing endoscopic

ampullectomy

If necessary, intraductal ablation was performed with wire-guided

RF or wire-guided cystotome

Retrospective analysis 2010-2016 73 patients (58 years)

EUS detected intraductal involvement in 16 (21.9%)

Intraducactal ablation with cystotome (n=14) and RFA (n=2),

followed with biliary and/or pancreatic stenting

Complications 19.2% (AP, bleeding, perforation, ductal stricture)

HGD (n=27, 37%) and adenocarcinoma (n=6, 8.2%)

FU 23 months: Recurrence (16.4%) and surgery (3 pt)

Multivariate analysis: only repeated endoscopic sessions >2

were associated with recurrence

OP362: MISER RCT: MINIMALLY INVASIVE SURGERY VS

ENDOSCOPY FOR NECROTIZING PANCREATITIS

14Bang et al, UEG journal 5S, A153

Patients with necrotizing pancreatitis Walled-off necrosis

Minimally invasive

surgery

Laparoscopic KG with

internal debridement

or

VARD

Endoscopy

Initial transmural

drainage (single, multi

gate or dual)

And

Debridement if

necessary

Primary end-points: Composite of major complications (MOF, bleeding or fistula)/DeathSecondary end points: Treatment success (early/mid/late)

© UEG. 2016

APPROACHES TO WON: TENSION

Endoscopic step-up

approachETD ETN if needed

n = 51

Surgical step-up

approachPCD VARD if needed

n = 49

Major complications or

death during 6 m FU20% 28% NS

Mortality 18% 13% NS

No need for necrosectomy 41% 49% NS

Pancreatic fistula 5% 32% p=0.001

LOS 36 d 69 d p=0.03

Dutch Pancreaittis Study Group, Abstract UEGW 2016

TENSION trial: Multicenter RCT: 98 patients with infected WON

OP362: MISER RCT: MINIMALLY INVASIVE SURGERY VS

ENDOSCOPY FOR NECROTIZING PANCREATITIS

16Bang et al, UEG journal 5S, A153

Minimally invasive

surgery (n=32)

Endoscopy

(n=34)

40% required

debridement

MIS Endoscopy p

Primary end point 34.4% 5.9% 0.004

Treatment success

Early

Mid

Late

53.1%

81.3%

84%

97.1%

100%

96.2%

<0.001

0.01

0.19

Adverse effects 53.1% 41.2% 0.33

Mortality 6.3% 2.9% 0.61

LoS (days) 18.5 14 0.057

OP363:LAMS VS PLASTIC DPT….ACT 1

17Brewer-Guttierez et al, UEG journal 5S, A153

- Cost-effective analysis for patients receiving LAMS vs DPT for WON- Simulation based on a pre-determined decision tree based on

probabilities obtained from systematic review of the literature- Efficiency: Successful drainage without need for percutaneous or

surgical intervention

LAMS improves the effectiveness of endoscopic management of patients with WON

P0252:LAMS VS PLASTIC DPT….ACT 2

18Bang et al, UEG journal 5S, A248

Bang et al, Gut 2016

Interim analysis of ongoing RCT:EUS-guided drainage WON: Plastic vs LAMS

- Bleeding (n=3)- Buried stents (n=2)- After 3 weeks!!

LAMS

(12)

Plastic

(9)

AE

(6):50%

AE

(0):0%

Trial still ongoing but extraction

before 4 weeks

Endoscopic management

of WON (>20% necrosis)

Leeds et al, Gut 2016

P0252:LAMS VS PLASTIC DPT….ACT 2

20Bang et al, UEG journal 5S, A248

LAMS Plastic DPT p

Procedure duration (min) 15 42.5 <0.001

Resolution of pre-

intervention of SIRS

44.4% 69.2% 0.38

Treatment success 96.3% 88% 0.34

Adverse effects

Overall

Stent related

41.9

32.3

20.7

6.9

0.10

0.02

Number of re-interventions 1 1 0.78

Readmissions 29% 34.5% 0.78

LAMS (n=31) Plastic (n=29)

Extraction before 4 weeksAfter amendement, no

differences were found (6.5% vs

6.9%)

OP315: EUS GUIDED RFA FOR PREMALIGNANT PANCREATIC

TUMORS

21Barthet et al, UEG journal 5S, A248

Prospective multicenter French study (9/15-2/17)

Patients with premalignant lesions who are unfit

or refuse surgery:

Side branch IPMNs with worrisome features

Pancreatic NETs (<2cm)

MCA

EUS-guided RFA

End points:

Safety

Efficacy at 1 year FU

RFAHeat

injury

Immunomodulation

Cytokine

s

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OP315: EUS GUIDED RFA FOR PREMALIGNANT PANCREATIC

TUMORS

Barthet et al, UEG journal 5S, A248

Complications 3/30 (10%)

AP

Delayed perforation

Pancreatic duct stricture

12

18

PATIENTS N=30

PNET CYSTIC T.

3

6

3

PNET:13.4 mm (8-20mm)

HEAD BODY TAIL

14

3

1

CYSTIC T. 29.1 mm (9-60 mm)

HEAD BODY TAIL

NSAIDS Antibiotics Aspirating cystic liquid before

24

OP315: EUS GUIDED RFA FOR PREMALIGNANT PANCREATIC

TUMORS

Barthet et al, UEG journal 5S, A248

NETs:

At 6 months: Significant response 82%

7 had complete necrosis or disappearance

2 a diameter decrease >50 %,

2 had a diameter decrease <50%

1 a complete failure Cystic lesions:

At 6 months: Significant response 69%

7 complete resolutions , 2 PR diameter decrease >50%

1 partial response <50%

3 no response

Mural nodes disappeared in 10 /12 cases

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