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  • WE MAKE LIVES BETTER

    UTHSC SAN ANTONIO

    Biliary and Pancreatic Endoscopy Stones, Strictures, and IPMN

    Sandeep N. Patel, DO

    Director, Pancreas Center

    University of Texas Health Science Center, San Antonio, TX, USA

    Memorial Hermann Gastroentrology & Hepatology Symposium

    February 10, 2018

  • Role of Intraductal Endoscopy Overview

    Biliary

    • Stones

    • Indeterminate biliary strictures

    Pancreas

    • Stones

    • IPMN

  • EndoscopicRetrogradeCholangioPancreatography Diagnosis

    Fluoroscopic imaging

    Therapy:

     Sphincterotomy

     Stenting

     Dilation

     Sampling

  • Intraductal Endoscopy Evolution

    Single-Operator technique mother-baby system

    2007 1970’s

  • Intraductal Endoscopy Evolution

    SpyGlass DS

    2015

  • WE MAKE LIVES BETTER

    UTHSC SAN ANTONIO

    Indeterminate biliary strictures and filling defects..

  • Sampling of CBD Strictures ERCP

    Yield:

    – brush ~ 30%

    – biopsy ~ 30%

    • Serial brushing

    • Dilation and brush

    • Novel brushes

    • “Smash” technique

    30-50%

  • Sampling of CBD Strictures Directed biopsies using SpyGlass

    • 56 yo female with recurrent cholangitis

    • Undergoes 3 ERCP’s at OSH – Filing defect CHD/stricture

    – Brushings, biopsies negative for CA

    – Prematurely occludes stents

    • Referred for management

    • What should we do ?

  • WE MAKE LIVES BETTER

    UTHSC SAN ANTONIO

    Case #1

  • Sampling of CBD Strictures Directed biopsies using Digital SpyGlass

  • WE MAKE LIVES BETTER

    UTHSC SAN ANTONIO

    Case #2

  • Sampling of CBD Strictures Directed biopsies using Digital SpyGlass

  • WE MAKE LIVES BETTER

    UTHSC SAN ANTONIO

    ™ Case #3

  • Results from Biopsy of Indeterminate Biliary Strictures – Does Direct Visualization Help? A Multicenter

    Experience

    Presented by K.F. Binmoeller, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA

    Registry Data tissue acquisition-SpyGlass

    Analysis of the data set of indeterminate strictures - intrinsic (intralumenal)

    Sensitivity 78% (21/27) Specificity 64% (7/11)

    Positive Predictive Value 95% (21/22)

    Negative Predictive Value 58% (7/12)

    Analysis of total data set of indeterminate strictures - extrinsic and intrinsic (intralumenal)

    Sensitivity 59% (23/39) Specificity 75% (3/4)

    Positive Predictive Value 100% (23/23)

    Negative Predictive Value 20% (3/15)

  • .

    Role of single-operator peroral cholangioscopy in the

    diagnosis of indeterminate biliary lesions: a single-

    center, prospective study.

    Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Darisetty S,

    Sekaran A, Rao GV.

    Gastrointest Endosc. 2011 Sep;74(3):511-9

    • The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36).

    • The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis.

    http://www.ncbi.nlm.nih.gov/pubmed?term="Ramchandani M"[Author] http://www.ncbi.nlm.nih.gov/pubmed?term="Reddy DN"[Author] http://www.ncbi.nlm.nih.gov/pubmed?term="Gupta R"[Author] http://www.ncbi.nlm.nih.gov/pubmed?term="Lakhtakia S"[Author] http://www.ncbi.nlm.nih.gov/pubmed?term="Tandan M"[Author] http://www.ncbi.nlm.nih.gov/pubmed?term="Darisetty S"[Author] http://www.ncbi.nlm.nih.gov/pubmed?term="Sekaran A"[Author] http://www.ncbi.nlm.nih.gov/pubmed?term="Rao GV"[Author]

  • Can we do even better?

    • 58 yo male newly diagnosed PSC

    • Pruritic

    • CA-19 high

    • No dominant strictures

    Does he have cancer ?

    Where ?

  • Sequela:

    • Abdomnal pain

    • Jaundice

    • Cholangitis

    • Acute Pancreatitis

  • ERCP Stone Extraction

    Techniques Success

    Sphincterotomy/extraction balloon/basket 80%

    Mechanical lithotripter 90%

    Binmoeller KF, Soehendra N, et al., Endoscopy 1993

  • ERCP Stone Extraction “limitations”

    Difficult stones

    Altered anatomy

    Stone(s) above a stricture Intrahepatic stones

    Large BD stones (>2cm)

  • ERCP Stone Extraction success rate

    Techniques Success

    Sphincterotomy/extraction balloon/basket 80%

    Mechanical lithotripter 90% 1

    1. Binmoeller KF, Soehendra N, et al., Endoscopy 1993

    2. Maydeo A, Kwek BE, et al. GIE 2011

    EHL/Laser ~100% 2

  • Electrohydrolylic Lithotripsy (EHL)

    • Spark between electrodes at fiber tip.

    • Sparks induces a spherical shock wave.

    • Shock wave oscillates to fragment the stone.

    • Done under direct visualization

    ** Very high energy **

  • Author n Clearance Complications

    Liguory19 17 94%

    Bonnel20 50 92% hemobilia = 21

    Binmoeller21 65 98% cholangitis = 22

    Siegal22 21 86% pancreatitis = 3

    Yoshimoto23 31 97% perforation = 3

    Adamek24 46 74% hemothorax = 1

    Arya25 94 90% bile leak = 1

    Piraka18 30 81%

    Others * 138 83%

    n = 492  89% 51/492 (10%)

    Electrohydraulic Lithotripsy for Common Bile Duct Stones

    * Summary of studies (23) with < 15 pts.

    Patel S, Rosenkranz L. ERCP for stone burden in the bile and pancreatic ducts. Clin of North A merica 2012.

  • Light Amplification by Stimulated Emission of Radiation

  • Various Lasers

    • Several are available

    • Differ in:

    • wavelength

    • pulse length

    • pulse energy

    Aluminum

    Erbium

    Holmium Neodymium

    Yttrium

  • Why Holmium??

    • Wavelength (2120 nm) = water

    • Low pulse length low energy shock wave

    **** Equally effective, less traumatic *****

    Vassar et al. J Endourol 1999

  • Laser Lithotripsy

    • Pulsed laser causes instantaneous fluid evaporation

    • This induces formation of cavitation bubble

    • Bubble collapse leads to shock wave

    “ photo-mechanical effect”

    • Bigger the bubble --> stronger the mechanical effect

  • Holmium:YAG laser safety data on bile duct epithelium in the porcine model

    • 6 female 50 kg domestic pigs underwent necropsy and the bile ducts

    (BD) were explanted.

    Sandeep Patel, Dustin Kiker, Joanna Lindsteadt, Bryan Hanysak. GIE 2009

    0

    10

    20

    30

    40

    50

    60

    s

    8 9 10 12 14 15

    W

    Median Time to Perforation

    Statistically Significant Differences in Time to Perforation*

    8 W vs 15 W

    9 W vs 15 W

    10 W vs 15 W

    12 W vs 15 W

    * Pairwise multiple comparison by Dunn's Method (P

  • Refractory Stone Extraction laser lithotripsy

    10W with 365  probe

  • S. Patel, L. Rosenkranz, B. Hooks, P. Tarnasky, D. Fishman, I. Raijman,, B. Sauer, M. Kahaleh. GIE 2014

    Total number of patients 74

    Extrahepatic stones 57/74 (77.2%)

    Intrahepatic stones 8/74 (10.3%)

    Cystic duct stones 4/74 (5.4%)

    Pancreatic stones 5/74 (6.8%)

    Prior failed ERCP attempts µ=1.4 (1-6)

    Sessions needed for ductal clearance µ=1.2

    Patients requiring one session 23/31 (74.2%)

    Attained ductal clearance

    a) biliary

    b) pancreatic

    67/ 69 (97.3%) 7/10 (70%)

    Procedural time µ=69 min (5-105 min)

    Procedural-related complications 3/74 (4.1%)

    74 pts (27 male, 47 female; mean age of 60.2 years ranging from 20-96)

    underwent holmium:YAG lithotripsy at four participating centers.

    Holmium-YAG Laser Lithotripsy in the Treatment of Pancreaticobiliary Calculi Utilizing (SpyGlass): A Multi-Center Trial.

  • Author n clearance complications

    FREDDY

    Cho31 52 92% 23%

    Lui32 30 90% 7%

    Kim33 17