Stuart Sherman, MD, FACG

Endoscopic Management in Acute Pancreatitis

Stuart Sherman, M.D.

Indiana University Medical Center

Indianapolis, Indiana

Endotherapy of Pancreas Disease

• ERCP traditionally avoided for pancreas

indications because of concern for

procedure-related pancreatitis

• Two developments led to more

widespread use

–Recognition of relative safety in setting of

gallstone pancreatitis

–Development of endoscopic and

pharmacologic methods to decrease rate

of post-ERCP pancreatitis

Stuart Sherman, MD, FACG

Endoscopic Therapy of

Pancreatic Disease

• Acute pancreatitis – Gallstones – Sphincter of Oddi dysfunction – Pancreas divisum – Choledochocele – Tumor

• Chronic pancreatitis – Strictures – Stones – CBD stricture

• Complications of pancreatitis – Pseudocysts and fistula – Necrosis

Gallstone Pancreatitis

Stuart Sherman, MD, FACG

Gallstone Pancreatitis:

Endoscopic Rx

• Prospective randomized controlled trial

• Gallstones suspected by US and/or

biochemical tests

• 121 patients Rx’d conventionally or by urgent

(< 72 hr) ERCP/ES and stone extraction

• Patients stratified according to predicted

severity based on modified Glasgow criteria

Neoptolemos. Lancet 1988;2:975.

Urgent ERCP (<72 hr) vs Conventional

Rx For Acute Gallstone Pancreatitis

Group / Treatment N Complications Death

Mild – Conventional 34 12% 0%

Mild – ERCP/ES 34 12% 0%

Severe – Conventional 28 61%* 18%

Severe – ERCP/ES 25 24% 4%

*p=0.007 (vs conventional)

Neoptolemos. Lancet 1988;2:979

Stuart Sherman, MD, FACG

Group /

Treatment N

Overall

Complications

Biliary

Sepsis Death

Mild –

Conventional 35 17% 11% 0%

Mild –

ERCP/ES 34 18% 0% 0%

Severe –

Conventional 28 54% 29% 18%*

Severe –

ERCP/ES 30 13% 0% 3%

*p=0.07 (vs conventional); **p=0.003

Fan. NEJM 1993;328:228

Emergent ERCP (< 24 hr) vs

Conventional Rx For Gallstone Pancreatitis

**

Acute Gallstone Pancreatitis:

Endoscopic Rx

• 238 gallstone pancreatitis patients randomized within 72 hours of symptom onset to ERCP/ES (n=126) or conservative Rx (n=112)

• Patients with biliary obstruction (>5 mg/dl) or cholangitis excluded

• Severity of AP based on modified Glasgow criteria

Fölsch. NEJM 1997;336:237.

Stuart Sherman, MD, FACG

ERCP vs Conventional Rx For Acute

Gallstone Pancreatitis

Treatment Group

Complication

Conservative

(n=112)

ERCP/ES

(n=126) p value

Pancreatic 22% 23% .98

Resp. Failure 5% 12% .03

Jaundice 11% 1% .02

Cholangitis 12% 14% .81

Renal Failure 4% 7% .10

Total Complications 51% 46%* .54

Death from ABP 4% 8%* .16

*No difference based on severity of AP.

Fölsch. NEJM 1997;336:227.

Gallstone Pancreatitis – Role of ERCP

8 RCT + 6 meta-analysis

1. Early ERCP in the absence of coexisting cholangitis or

biliary obstruction DOES NOT lead to a reduction in

mortality and local or systemic complications

2. Patient outcomes are not dependent on predicted severity

of pancreatitis

3. ERCP is not indicated for gallstone pancreatitis alone

regardless of pancreatitis severity

4. ERCP should be done when gallstone pancreatitis is

complicated by biliary obstruction or cholangitis

Fogel, Sherman NEJM (In Press)

Conclusions

Stuart Sherman, MD, FACG

Pancreas Divisum

• Most common congenital variant of PD anatomy

• Occurs when dorsal and ventral ducts fail to fuse

• With duct nonunion, the major portion of the exocrine juice drains into the duodenum via the dorsal duct and minor papilla

• Common cause of unexplained recurrent pancreatitis

Pancreas Divisum

Stuart Sherman, MD, FACG

Pancreas Divisum

Minor Papilla

Stuart Sherman, MD, FACG

• Aim to alleviate the outflow

obstruction

• Methods: dilation, ES, stenting

Pancreas Divisum: Endoscopic Therapy

Dorsal Duct Stent

Stuart Sherman, MD, FACG

Minor Papilla ES

Pancreas Divisum

Stuart Sherman, MD, FACG

Minor Papilla Rx for Pancreas Divisum and ARP

12 studies 1986-2009

No. pts. Follow-up

(mos) Improved

241 30 76%

Pancreas Divisum and ARP:

Results for Minor Papilla Stenting

Therapy

F/U

(mo)

Hosp.

ER

Number

w/panc.

Improved

Stent (n=10)

29 0 0 1 9 (90%)

Control (n=9)

32 5* 2 7* 1 (11%)*

P<.05; Lans. GI Endosc 1992;38:430

Stuart Sherman, MD, FACG

• Patients with pancreas divisum and acute recurrent pancreatitis are good candidates for minor papilla therapy

• Long-term outcome studies and further RCTs of endoscopic therapy are needed

Conclusion: ARP Due to Pancreas Divisum

Sphincter of Oddi Dysfunction

Stuart Sherman, MD, FACG

Sphincter of Oddi

Triple Lumen Catheter

Stuart Sherman, MD, FACG

Sphincter of Oddi Manometry

SO Manometry Tracing

Stuart Sherman, MD, FACG

Sphincter of Oddi Dysfunction Causing IARP

(9 series 1985-2010)

No. patients Frequency SOD

1757 698 (40%)

Does Biliary Sphincterotomy Alone

“Cure” Pancreatitis in SOD?

Therapy # Pts. F/U Asymptomatic

Biliary ES 16 5 yr 44%

Sherman. GIE 1993;39:331A

Stuart Sherman, MD, FACG

Pancreatic Sphincterotomy

ARP and Increased Pancreatic Sphincter Pressure: Need for Ablation of Both Biliary and Pancreatic Sphincters

Number Pts Therapy N Improved BD ES 18 5 (28%)

BD ES + PD balloon 24 13 (54%) dilation

BD ES + PD ES 27 22 (81%)

p < .001

Guelrud. GI Endosc 1995;41:398A

Stuart Sherman, MD, FACG

IARP – RCT of BDES vs. BDES + PDES for Pancreatic SOD

(f/u 7 years)

Coté. Gastro 2012

p = 1

• SOD is the most common cause of IARP when detailed endoscopic evaluation performed

• Sphincter of Oddi manometry is the gold standard for diagnosing SOD

• The best therapy awaits further study

– At present, the role of sphincter therapy remains unclear

Conclusions: IARP Due to SOD

Stuart Sherman, MD, FACG

Pseudocysts

Pseudocyst

• Localized collections of pancreatic juice

• Enclosed by a non-epithelialized wall

• Arise as consequence of acute pancreatitis, chronic pancreatitis, or pancreatic trauma*

• Typically require 4 weeks to form

* Arch Surg 1993;128:586

Stuart Sherman, MD, FACG

Pseudocysts:

Endoscopic Therapy

• Transpapillary

• Transmural – Cystogastrostomy

– Cystoduodenostomy

• Combined techniques

• EUS and/or ERCP

Stuart Sherman, MD, FACG

Pseudocyst Drainage

Endoscopic Cystoenterostomy

• Aim: Create a communication between

cyst cavity and gastric or duodenal

lumen

• Two prerequisites should be fulfilled

when doing video endoscopy – Visible bulge

– Cyst-to-lumen distance < 1 cm

– EUS has expanded patient population eligible

for endoscopic drainage

Stuart Sherman, MD, FACG

Transmural Drainage

of Pseudocyst

Transmural Drainage

of Pseudocyst

Stuart Sherman, MD, FACG

Pseudocyst Drainage

Potential Advantages of EUS-guided

Drainage over “Blind Puncture”

• Avoidance of intervening vascular structures including varices

• Assess degree of necrosis

• Determine maturity of cyst wall

• Easier sampling to rule out mucinous neoplasm

• Visible bulge not necessary for drainage

Stuart Sherman, MD, FACG

RCT: EUS-Guided vs. Conventional

Transmural Drainage of Pseudocysts

Outcome EUS

(n=31)

Conventional

(n=29) P-val

Technical Success 94% 72%* .039

Complications 7% 10% .67

Short-term resolution 97% 91% .57

Long-term resolution 89% 86% .70

Park. Endosc 2009;41:842.

*8 nonbulging cysts successfully treated by EUS on crossover

Endoscopic Therapy of Pseudocysts

(15 Series, ERCP + EUS; 1985-2002)

No.

pts.

Initial

Resolution Recur Complic Mortality

632 87% 15% 16% .3%

Stuart Sherman, MD, FACG

RCT: Endoscopic vs. Surgical

Cystgastrostomy for Pseudocyst Drainage

Outcome EUS + ERCP

(n=20)

Open Surgery

(n=20) P-val

Success 95% 100% .5

Recurrence (24 mos) 0% 5% .5

Complications 0% 10%` .24

Hospital stay 2d 6d <.001

Hospital costs ($) 7,011 15,052 .003

Varadarajulu. Gastro 2013;145:583.

Pancreatic Necrosis

Stuart Sherman, MD, FACG

Acute Pancreatitis

• Interstitial pancreatitis – 80% • Pancreas is inflamed but viable

• Usually mild; focal and systemic complications rare

• Secondary complications rare; infection is unusual

• Mortality <2%

• Necrotizing pancreatitis – 20% • Systemic toxicity is common

• Infection may occur in 30% - 50%

• Mortality, 10% in sterile necrosis; 30% in infected necrosis

• Distinction based on contrast-enhanced CT scan

48

pancreas

fluid

Interstitial Pancreatitis

Stuart Sherman, MD, FACG

49

fluid

stranding

necrosis

Necrotizing Pancreatitis

Organized Pancreatic Necrosis →

Walled Off Pancreatic Necrosis

Stuart Sherman, MD, FACG

Endoscopic Drainage

Outcome After

Endoscopic Drainage

N

Initial

resolution

Hosp

Days

Complic Recur “Cure”

Acute

Pcyst

31 74% 9 19% 9% 68%

Chronic

Pcyst

64 92% 3 17% 12% 81%

Organized

necrosis

43 72% 20 37% 29% 51%

Baron. GIE 2002;56:7

Stuart Sherman, MD, FACG

RCT: Open Necrosectomy vs. Minimally Invasive “Step Up”

Approach for Infected Pancreatic Necrosis (n=88)

Step Up

Open

Necrosectomy

p

value

Major complication or death 40% 69% .006

Multiorgan failure 12% 40% .002

Incisional hernias 7% 24% .03

Diabetes 16% 38% .02

Exocrine insufficiency 7% 33% .002

Healthcare utilization Lower <.001

Total cost $116,016 $131,979

NEJM 2010;362:1491.

Step up approach: Percutaneous or endoscopic drainage; video-

assisted retroperitoneal debridement (VARD) if no improvement

Stuart Sherman, MD, FACG

2013 – When is Endoscopic

Treatment Indicated in Acute Recurrent

Pancreatitis – Conclusions

Disorder No Yes

Gallstone pancreatitis √

Cholangitis; BD obst √

Pancreas divisum √

SOD ?

Pseudocyst √

Pancreatic necrosis √