Pancreas: Standards and Innovations€¦ · Chronic pancreatitis early stage/minimal changes •N =...
Transcript of Pancreas: Standards and Innovations€¦ · Chronic pancreatitis early stage/minimal changes •N =...
Pancreas: Standards and Innovations
Jacques DEVIERE, MD, PhDErasme University Hospital
Brussels – [email protected]
• 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