Pancreatobiliary Cancer: The Role of ERCP, EUS, and Cholangioscopy

Jonathan Gonenne, MD

Eugene Gastroenterology Consultants

April 27, 2013

Disclosures

• None

Patient #1 66-year-old male referred for several weeks of progressive abdominal pain and jaundice…

Pancreatobiliary Cancer: The Role of ERCP, EUS, and Cholangioscopy

Bilirubin 10

CT-Pancreas head mass 3.5 cm with dilated bile duct

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• ERCP

Endoscopic retrograde cholangiopancreatography

ERCP

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• EUS-Endoscopic ultrasound

Endoscopic Ultrasound (EUS)

• What is EUS? • Anatomy • What are the indications? Fine Needle Aspiration (FNA)

Endoscopic Ultrasound (EUS)

• What is EUS? • Anatomy • What are the indications? Fine Needle Aspiration (FNA)

EUS: No incision, no anesthesia

Ultrasound Equipment

Linear Echoendoscope

Endoscopic Ultrasound (EUS)

• What is EUS? • Anatomy • What are the indications? Fine Needle Aspiration (FNA)

Pancreatic Cancer

Pancreatic Neuroendocrine Tumor

FNA Needles

FNA Needles

EUS FNA-Complications • The risk of acute pancreatitis after biopsy of

pancreatic masses was estimated in a pooled analysis of 19 centers involving a total of 4909 EUS-guided FNAs of solid pancreatic masses. Pancreatitis occurred after 14 procedures (0.29 percent). Pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in 1.

• The risk of bacteremia appears to be very low

Antibiotic prophylaxis has been recommended prior to FNA of cystic lesions.

Endoscopic Ultrasound (EUS)

• What is EUS? • Anatomy • What are the indications? • Fine Needle Aspiration (FNA)

Endoscopic Ultrasound (EUS)

• What is EUS? • Anatomy

• What are the indications? Fine Needle Aspiration (FNA)

Pancreatic Cancer • Patients with unresectable cancer • Patients with resectable tumors whenever patient/MD

feels a diagnosis is necessary prior to proceeding with surgery

• i.e. doubt if mass is benign or malignant (focal pancreatitis)

• We do not always perform if tumor appears resectable by CT and EUS as this doesn’t alter the decision to proceed with surgery

Pancreatobiliary Cancer: The Role of ERCP, EUS, and Cholangioscopy

Patient #2

83-year-old male referred for several weeks of weight loss and jaundice…

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Bilirubin 25

CT- “… concern for a developing, obstructing mass in the region of the left hepatic duct and the confluence forming the common hepatic duct”

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Cholangioscopy

Pancreatobiliary Cancer: The Role of ERCP, EUS, and Cholangioscopy

ERCP/Stenting--a bridge to surgery in patients with resectable disease and for palliation in patients with biliary obstruction

EUS-FNA -- provides complementary staging modality and cytologic diagnosis

Cholangioscopy-directed tissue biopsies improves accuracy for detecting malignancy