Pancreas: Standards and Innovations€¦ · Chronic pancreatitis early stage/minimal changes •N =...
Transcript of Pancreas: Standards and Innovations€¦ · Chronic pancreatitis early stage/minimal changes •N =...
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Pancreas: Standards and Innovations
Jacques DEVIERE, MD, PhDErasme University Hospital
Brussels – [email protected]
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• Diagnosis• Stones, strictures• « Cysts », necrosectomy
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Diagnosis: MRI and EUS haveERCP as standards
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S-MRCP and Pancreas divisum
Normal response to stimulation
S0 S5 S10
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Minor papilla dysfunction (25 y-old F)
baseline
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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
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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
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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
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s-MRCP and IPMT
S– S+S+
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Duodenal duplication cyst• 17 y-old female, 3 episodes of acute pancreatitis / 8 months
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Diffusion weighted imagingMRI gives PET-scan like opportunities
from Takeuchi et al. ECR 2007
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DWI : Pancreatic cancer
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DWI and autoimmune pancreatitis
Post Rxwith steroids
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Severe Chronic Pancreatitis
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ObtainedObtained afterafter a a medianmedian of 1 session of 1 session
withwith thethe highhigh power, Xpower, X--ray ray focusedfocused
machinesmachines
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Guda NM, JOP 2005; 6: 6-12
ESWL/ET in the Management of Chronic Pancreatitis: A Meta-Analysis Effect on pain
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balloon dilation4 mm x 4 cm
pancreaticstent
5 cm x 10F
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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
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• 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
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Multiple Pancreatic Stenting
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• 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
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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%
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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
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Assessing treatments: ESWL alone in CP
Dumonceau et al, GUT 2007
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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
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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 ?
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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
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Disconnected pancreatic tail syndrom:A model for multitechnical approach
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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
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Pancreatic duct leakageRoad map before and after therapy
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Extending our way to notesInfected necrosis (gastric bypass)
Voermans et al,GI Endosc 2007
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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
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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
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When the collection has been drained (necrosis), only a fistula remains
Fistula tract opacified
Arvanitakis et al, AJG 2007
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Catheter loaded with a guidewire is positioned in the paraduodenal virtual PFC,which is identified by EUS after water/contrast injection
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EUS-guided transmural drainage of the virtual cavity and insertion of a double pig-tail stent
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Conclusion
Percutaneous
MRIEUS
ERCP
Performed by the same teamand available « when needed »With surgeons on a daily basis
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GEEWJune 22-24, 2009
Brussels
www.live-endoscopy.com