This document discusses endoscopic diagnosis and management of bile duct cancers. It covers pre-procedure evaluation with imaging to determine resectability. Tissue diagnosis methods include ERCP with cytology/biopsy, EUS-FNA, and cholangioscopy-guided biopsies. Unresectable cancers are palliated endoscopically with stenting. Debate around unilateral vs. bilateral stenting and plastic vs. metal stents is summarized. Overall it provides an overview of endoscopic evaluation and treatment approaches for bile duct cancers.
Indeterminate biliary strictures refer to biliary strictures without an identifiable cause on imaging. The endoscopist's role is to determine if the stricture is benign or malignant and offer treatment options. Available tools for evaluation include ERCP, cholangioscopy, intraductal ultrasound (IDUS), and endoscopic ultrasound (EUS). ERCP allows for tissue sampling but has a sensitivity of only 30-55%. Newer techniques like fluorescence in-situ hybridization and confocal endomicroscopy can increase sensitivity. Direct visualization with cholangioscopy may improve detection over standard ERCP. IDUS provides high accuracy in differentiating benign from malignant strictures without direct sampling. EUS allows for
Indeterminate biliary strictures refer to biliary strictures without an identifiable cause on imaging. The endoscopist's role is to determine if the stricture is benign or malignant and offer treatment options. Available tools for evaluation include ERCP, cholangioscopy, intraductal ultrasound (IDUS), and endoscopic ultrasound (EUS). ERCP allows for tissue sampling but has limited sensitivity. Newer techniques like fluorescence in-situ hybridization and confocal endomicroscopy show promise to improve detection. Direct visualization with cholangioscopy may also improve detection over standard techniques. IDUS provides diagnostic accuracy without direct sampling. EUS allows for tissue acquisition with fine needle aspiration and evaluation of local
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche ...Gastrolearning
Gastrolearning II modulo/4a lezione
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche
Prof. A. Larghi - Università Cattolica Sacro Cuore (Roma).
Eus talk.novato.march 2010 converted to pptMUCINGroup
EUS is more accurate than MRCP or CT for evaluating pancreaticobiliary diseases like pancreatic cancer or pancreatic cysts. For the patient with suspected pancreatic cancer, EUS can detect small tumors missed by CT/MRI and more accurately determine if a tumor is resectable. EUS-FNA is the best method for obtaining a tissue diagnosis of a pancreatic mass, with a higher diagnostic yield and lower risk of complications than percutaneous or ERCP-guided biopsies. While ERCP can help with biliary decompression for unresectable tumors, it provides little additional information for diagnosis or staging of pancreatic cancer compared to EUS or CT/MRI.
1) EUS plays an important role in diagnosing and treating hepatobiliary diseases such as portal hypertension, focal liver lesions, cholangiocarcinoma, and pancreaticobiliary strictures when conventional approaches are not feasible or have failed.
2) EUS can be used to guide fine needle aspiration of liver lesions, create biliary drainage by choledochoduodenostomy or hepaticogastrostomy when endoscopic retrograde cholangiopancreatography fails, and treat conditions like hepatic abscesses and cysts.
3) Complication rates of EUS-guided biliary drainage are approximately 23% but the technique provides a safer alternative to percutaneous drainage in many cases.
This document reviews interventional endoscopic ultrasound (EUS) procedures, including EUS-guided fine needle aspiration (FNA). EUS-FNA is a safe and accurate procedure used to diagnose lesions in the esophagus, pancreas, lymph nodes, liver, lungs and other organs. It has a diagnostic accuracy of 64-94% for pancreatic masses. EUS also guides drainage of pancreatic pseudocysts and bile ducts when conventional endoscopy fails. Emerging applications include EUS-guided celiac plexus neurolysis for pain relief, fiducial placement for tumor localization, and ablation techniques for treating pancreatic cysts and tumors. In summary, the document outlines the various diagnostic and therapeutic applications of
1. Interventional EUS allows drainage of pseudocysts and abscesses as well as injection of substances like ethanol, chemotherapy drugs, and gene therapies.
2. EUS guided techniques can be used to drain pancreatic pseudocysts and perform biliary drainage with higher success rates than endoscopy alone.
3. Emerging interventional EUS therapies include ablation techniques like ethanol injection, radiofrequency ablation, and brachytherapy to treat pancreatic tumors.
Eus talk.novato.march 2010 converted to pptMUCINGroup
EUS is more accurate than MRCP or CT for evaluating pancreaticobiliary diseases like pancreatic cancer or pancreatic cysts. For the patient with suspected pancreatic cancer, EUS can detect small tumors missed by CT/MRI and more accurately determine if a tumor is resectable. EUS-FNA is the best method for obtaining a tissue diagnosis of a pancreatic mass, with a higher diagnostic yield and lower risk of complications than percutaneous or ERCP-guided biopsies. While ERCP can help with biliary decompression for unresectable tumors, it provides little additional information for diagnosis or staging of pancreatic cancer compared to EUS or CT/MRI.
Indeterminate biliary strictures refer to biliary strictures without an identifiable cause on imaging. The endoscopist's role is to determine if the stricture is benign or malignant and offer treatment options. Available tools for evaluation include ERCP, cholangioscopy, intraductal ultrasound (IDUS), and endoscopic ultrasound (EUS). ERCP allows for tissue sampling but has a sensitivity of only 30-55%. Newer techniques like fluorescence in-situ hybridization and confocal endomicroscopy can increase sensitivity. Direct visualization with cholangioscopy may improve detection over standard ERCP. IDUS provides high accuracy in differentiating benign from malignant strictures without direct sampling. EUS allows for
Indeterminate biliary strictures refer to biliary strictures without an identifiable cause on imaging. The endoscopist's role is to determine if the stricture is benign or malignant and offer treatment options. Available tools for evaluation include ERCP, cholangioscopy, intraductal ultrasound (IDUS), and endoscopic ultrasound (EUS). ERCP allows for tissue sampling but has limited sensitivity. Newer techniques like fluorescence in-situ hybridization and confocal endomicroscopy show promise to improve detection. Direct visualization with cholangioscopy may also improve detection over standard techniques. IDUS provides diagnostic accuracy without direct sampling. EUS allows for tissue acquisition with fine needle aspiration and evaluation of local
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche ...Gastrolearning
Gastrolearning II modulo/4a lezione
Il ruolo dell'ecoendoscopia nella diagnosi delle lesioni solide pancreatiche
Prof. A. Larghi - Università Cattolica Sacro Cuore (Roma).
Eus talk.novato.march 2010 converted to pptMUCINGroup
EUS is more accurate than MRCP or CT for evaluating pancreaticobiliary diseases like pancreatic cancer or pancreatic cysts. For the patient with suspected pancreatic cancer, EUS can detect small tumors missed by CT/MRI and more accurately determine if a tumor is resectable. EUS-FNA is the best method for obtaining a tissue diagnosis of a pancreatic mass, with a higher diagnostic yield and lower risk of complications than percutaneous or ERCP-guided biopsies. While ERCP can help with biliary decompression for unresectable tumors, it provides little additional information for diagnosis or staging of pancreatic cancer compared to EUS or CT/MRI.
1) EUS plays an important role in diagnosing and treating hepatobiliary diseases such as portal hypertension, focal liver lesions, cholangiocarcinoma, and pancreaticobiliary strictures when conventional approaches are not feasible or have failed.
2) EUS can be used to guide fine needle aspiration of liver lesions, create biliary drainage by choledochoduodenostomy or hepaticogastrostomy when endoscopic retrograde cholangiopancreatography fails, and treat conditions like hepatic abscesses and cysts.
3) Complication rates of EUS-guided biliary drainage are approximately 23% but the technique provides a safer alternative to percutaneous drainage in many cases.
This document reviews interventional endoscopic ultrasound (EUS) procedures, including EUS-guided fine needle aspiration (FNA). EUS-FNA is a safe and accurate procedure used to diagnose lesions in the esophagus, pancreas, lymph nodes, liver, lungs and other organs. It has a diagnostic accuracy of 64-94% for pancreatic masses. EUS also guides drainage of pancreatic pseudocysts and bile ducts when conventional endoscopy fails. Emerging applications include EUS-guided celiac plexus neurolysis for pain relief, fiducial placement for tumor localization, and ablation techniques for treating pancreatic cysts and tumors. In summary, the document outlines the various diagnostic and therapeutic applications of
1. Interventional EUS allows drainage of pseudocysts and abscesses as well as injection of substances like ethanol, chemotherapy drugs, and gene therapies.
2. EUS guided techniques can be used to drain pancreatic pseudocysts and perform biliary drainage with higher success rates than endoscopy alone.
3. Emerging interventional EUS therapies include ablation techniques like ethanol injection, radiofrequency ablation, and brachytherapy to treat pancreatic tumors.
Eus talk.novato.march 2010 converted to pptMUCINGroup
EUS is more accurate than MRCP or CT for evaluating pancreaticobiliary diseases like pancreatic cancer or pancreatic cysts. For the patient with suspected pancreatic cancer, EUS can detect small tumors missed by CT/MRI and more accurately determine if a tumor is resectable. EUS-FNA is the best method for obtaining a tissue diagnosis of a pancreatic mass, with a higher diagnostic yield and lower risk of complications than percutaneous or ERCP-guided biopsies. While ERCP can help with biliary decompression for unresectable tumors, it provides little additional information for diagnosis or staging of pancreatic cancer compared to EUS or CT/MRI.
This document discusses endoscopic ultrasound (EUS) and provides information about its applications. It covers EUS imaging of the gastrointestinal tract walls and surrounding structures. Examples are given of EUS being used to image and diagnose conditions of the esophagus, stomach, pancreas, bile ducts, and surrounding blood vessels. Imaging characteristics and EUS findings are described for various tumors, cysts, and other abnormalities.
EUS enables sampling of lesions near the esophagus, stomach, duodenum, and rectum. The document describes a case of EUS-guided FNA of a gastric mass in a woman with weight loss, revealing a GIST. It also details a case of a large pancreatic head mass in a man with pancreatitis, where EUS-FNA obtained a diagnosis of pancreatic cancer. A third case involves EUS evaluation of mediastinal lymph nodes in a man with lung cancer history, with FNA to assess for recurrence. The type and size of EUS needle does not impact diagnostic yield, but rapid on-site cytopathology and experience improve efficacy.
The document discusses past, present, and future applications of endoscopic ultrasound (EUS)-guided anti-tumor therapy. It outlines how EUS can be used for diagnosis, local drug delivery, and ablation of pancreatic cysts and cancers. Current techniques include ethanol ablation, fiducial placement, brachytherapy, and vascular interventions. Future areas of research may involve photodynamic therapy, radiofrequency ablation, high intensity focused ultrasound, and combining EUS with natural orifice transluminal endoscopic surgery.
This document summarizes the current status of pancreaticobiliary endoscopic ultrasound (EUS) at Delhi Apollo Hospital. It finds that EUS, with or without fine needle aspiration (FNA), provides accurate diagnosis and staging of pancreaticobiliary lesions. In a study of 67 patients, EUS identified lesions in the pancreas, bile duct, ampulla, and detected cancers, cysts, stones. No complications occurred. The results are similar to other established centers and confirm EUS as a safe, accurate method for evaluating pancreaticobiliary diseases.
EUS Guided Interventions for Pancreatobiliary TumoursJarrod Lee
Endoscopic Ultrasound (EUS) has advanced rapidly in recent years, and has evolved from a primarily diagnostic tool, to one that has an increasing role in interventions. We review the latest roles of EUS guided interventions for pancreas and bile duct tumours.
The lecture was the plenary lecture at the Philippines National Endoscopy Conference 2014
EUS and EUS-FNA are effective techniques for evaluating submucosal lesions. The document reports on a study of 127 submucosal lesions that underwent EUS and EUS-FNA. EUS was able to determine the layer of origin and characteristics of the lesions. EUS-FNA provided a diagnosis in 56 cases and was concordant with the final diagnosis in most cases. EUS and EUS-FNA together allowed accurate diagnosis and differentiation of benign and malignant lesions in this study.
Eus beyond mucosa and beyond gastroenterologyAhmed Elwassief
This document discusses endoscopic ultrasound (EUS) and its expanding applications beyond just visualizing the gastrointestinal mucosa. EUS can now be used to obtain fine needle aspirations of mural, extra-mural, and pancreatic lesions. The document outlines the equipment, techniques, and indications for EUS, including using it to stage cancers, diagnose and treat benign lesions, and perform therapeutic procedures such as cyst drainage and neurolysis. EUS has proven useful in evaluating subepithelial masses, pancreatic cysts and masses, bile duct diseases, and performing biopsies with a high diagnostic yield. The role of EUS continues to grow as new therapeutic applications are developed.
1. The document presents Italian consensus guidelines for the diagnostic workup and follow up of cystic pancreatic neoplasms (CPNs).
2. It provides 52 statements with evidence levels and recommendations on topics including clinical evaluation, imaging, endoscopic ultrasound, cyst fluid markers, and pathology.
3. The guidelines are intended to standardize the evaluation and management of CPNs according to morphology and symptoms, while taking into account resources in the Italian healthcare system.
EUS is a new method for diagnosing disorders of the esophagus, stomach, bile and pancreatic ducts, and anal region, as well as intramural lesions of the gastrointestinal tract. It helps with staging of GI cancers and lung cancer by detecting lymph nodes. EUS allows for interventional diagnostic procedures like fine needle aspiration biopsy and drainage, as well as therapeutic procedures. It is well-suited for tumor staging according to the TNM classification by assessing tumor depth and presence of metastases. EUS-guided FNA biopsy provides superior cytopathological diagnosis of primary tumors and nodal metastases compared to other imaging methods.
EUS can be used to stage cancers of the esophagus, stomach, rectum, lung and diagnose pancreatic cancer. It allows evaluation of abnormalities in the GI tract wall and adjacent structures. EUS guided FNA biopsy enables cytopathological diagnosis of cancers and nodal metastases. EUS is well-suited for TNM tumor staging as it can assess depth of tumor penetration, locoregional nodal spread and vascular invasion. It also has applications in diagnosis of cholangiocarcinoma, evaluation of pancreatic cysts and masses, and celiac plexus neurolysis for pain relief.
The document discusses the management of liver metastases from colorectal cancer. It reports on a study that found perioperative chemotherapy with FOLFOX4 improved progression-free survival in patients with resectable liver metastases, especially in those whose metastases were resected. The study established perioperative chemotherapy as the new standard of care for these patients. It also discusses challenges in treating colorectal cancer patients with only liver metastases and strategies for increasing resection rates and long-term survival, including optimizing systemic therapies and utilizing a multidisciplinary team approach.
This document discusses the use of chromoendoscopy and narrow band imaging (NBI) with magnification for detecting and diagnosing squamous cell carcinomas (SCCs) in the esophagus and pharynx. It outlines various dyes used in chromoendoscopy and describes findings on NBI like brownish areas and irregularities in intra-epithelial papillary capillary loops that indicate early SCCs. Studies show NBI has significantly higher detection and diagnostic accuracy rates than white light imaging for SCCs in both locations. NBI classification systems are presented to diagnose SCC depth.
Ntc dr muthusamy bridge to surgery talk final 6 18MUCINGroup
This document discusses endoscopic evaluation and staging of pancreatic cancer. It begins by outlining the algorithm for evaluating suspected pancreatic cancer with CT/MRI and EUS. Key questions after detecting a pancreatic mass include determining resectability and predicting tumor stage. Stages are defined as resectable, borderline, locally advanced, and metastatic based on criteria such as vascular involvement. Examples of EUS images illustrating resectable, locally advanced, and borderline resectable cancers are provided. The document concludes that neoadjuvant therapy is increasingly used for borderline resectable pancreatic cancer and requires durable biliary drainage during treatment.
EUS has revolutionized both the diagnostic and therapeutic aspects of gastroenterology. It combines an endoscope with an ultrasound probe to examine the GI tract walls and nearby structures. EUS is very useful for staging cancers of the esophagus, pancreas, and biliary tract, and is the most sensitive method for distinguishing between benign and malignant pancreatic tumors. EUS also has several important therapeutic roles, including draining pancreatic fluid collections, accessing the biliary tree non-surgically, celiac plexus neurolysis for pancreatic cancer pain relief, and delivering targeted cancer treatments. Recent advances have further increased the diagnostic and therapeutic capabilities of EUS.
Benign Biliary Stricture is a common condition which we encounter during gastro practice. Here we discuss in detail about its diagnosis and management.
CT urography (CTU) is highly accurate for detecting bladder cancer in high-risk patients. A retrospective study of 45 high-risk patients found that CTU had a 97% sensitivity and 80% specificity for bladder cancer detection compared to flexible cystoscopy. Multivariate analysis showed that positive CTU findings were highly significant predictors of bladder cancer diagnosis. The study suggests that in high-risk patients with positive CTU findings, flexible cystoscopy could be omitted and patients referred directly for rigid cystoscopy and potential biopsy or resection. However, the study had some limitations due to the small sample size.
This document discusses treatment options for cancer of the esophagus. It covers staging, endoscopic resection options for early stage cancers, preoperative chemoradiation followed by surgery as standard treatment for locally advanced cancers, and types of surgery and postoperative care. Chemotherapy regimens including cisplatin and fluorouracil provide response rates of 20-30% for metastatic cancers. Overall, the document provides an overview of current guidelines and evidence for endoscopic, surgical, radiation, and chemotherapy approaches to esophageal cancer treatment based on tumor stage.
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi - Gastro...Gastrolearning
Gastrolearning II modulo/7a lezione
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi
Prof. D. Alvaro - Università di Roma La Sapienza
Gallstone disease is common, with cholesterol stones forming due to cholesterol saturation and gallbladder dysmotility. Complications include biliary colic, cholecystitis, cholangitis, and pancreatitis. Choledocholithiasis presents with biliary symptoms and jaundice and is treated with ERCP and sphincterotomy. Acalculous cholecystitis occurs in critically ill patients and requires urgent cholecystectomy or percutaneous drainage. Choledochal cysts are congenital anomalies of the biliary tree classified by Todani type and often require surgical excision.
This document provides information on pancreatic adenocarcinoma, including its anatomy, physiology, clinical presentation, investigations, staging, treatment and prognosis. It discusses the exocrine and endocrine functions of the pancreas. It also covers cystic lesions of the pancreas and pancreatic endocrine tumours. The staging and survival rates for pancreatic cancer are presented. Complications of pancreatic surgery and mortality rates at high volume centers are summarized.
This document discusses endoscopic ultrasound (EUS) and provides information about its applications. It covers EUS imaging of the gastrointestinal tract walls and surrounding structures. Examples are given of EUS being used to image and diagnose conditions of the esophagus, stomach, pancreas, bile ducts, and surrounding blood vessels. Imaging characteristics and EUS findings are described for various tumors, cysts, and other abnormalities.
EUS enables sampling of lesions near the esophagus, stomach, duodenum, and rectum. The document describes a case of EUS-guided FNA of a gastric mass in a woman with weight loss, revealing a GIST. It also details a case of a large pancreatic head mass in a man with pancreatitis, where EUS-FNA obtained a diagnosis of pancreatic cancer. A third case involves EUS evaluation of mediastinal lymph nodes in a man with lung cancer history, with FNA to assess for recurrence. The type and size of EUS needle does not impact diagnostic yield, but rapid on-site cytopathology and experience improve efficacy.
The document discusses past, present, and future applications of endoscopic ultrasound (EUS)-guided anti-tumor therapy. It outlines how EUS can be used for diagnosis, local drug delivery, and ablation of pancreatic cysts and cancers. Current techniques include ethanol ablation, fiducial placement, brachytherapy, and vascular interventions. Future areas of research may involve photodynamic therapy, radiofrequency ablation, high intensity focused ultrasound, and combining EUS with natural orifice transluminal endoscopic surgery.
This document summarizes the current status of pancreaticobiliary endoscopic ultrasound (EUS) at Delhi Apollo Hospital. It finds that EUS, with or without fine needle aspiration (FNA), provides accurate diagnosis and staging of pancreaticobiliary lesions. In a study of 67 patients, EUS identified lesions in the pancreas, bile duct, ampulla, and detected cancers, cysts, stones. No complications occurred. The results are similar to other established centers and confirm EUS as a safe, accurate method for evaluating pancreaticobiliary diseases.
EUS Guided Interventions for Pancreatobiliary TumoursJarrod Lee
Endoscopic Ultrasound (EUS) has advanced rapidly in recent years, and has evolved from a primarily diagnostic tool, to one that has an increasing role in interventions. We review the latest roles of EUS guided interventions for pancreas and bile duct tumours.
The lecture was the plenary lecture at the Philippines National Endoscopy Conference 2014
EUS and EUS-FNA are effective techniques for evaluating submucosal lesions. The document reports on a study of 127 submucosal lesions that underwent EUS and EUS-FNA. EUS was able to determine the layer of origin and characteristics of the lesions. EUS-FNA provided a diagnosis in 56 cases and was concordant with the final diagnosis in most cases. EUS and EUS-FNA together allowed accurate diagnosis and differentiation of benign and malignant lesions in this study.
Eus beyond mucosa and beyond gastroenterologyAhmed Elwassief
This document discusses endoscopic ultrasound (EUS) and its expanding applications beyond just visualizing the gastrointestinal mucosa. EUS can now be used to obtain fine needle aspirations of mural, extra-mural, and pancreatic lesions. The document outlines the equipment, techniques, and indications for EUS, including using it to stage cancers, diagnose and treat benign lesions, and perform therapeutic procedures such as cyst drainage and neurolysis. EUS has proven useful in evaluating subepithelial masses, pancreatic cysts and masses, bile duct diseases, and performing biopsies with a high diagnostic yield. The role of EUS continues to grow as new therapeutic applications are developed.
1. The document presents Italian consensus guidelines for the diagnostic workup and follow up of cystic pancreatic neoplasms (CPNs).
2. It provides 52 statements with evidence levels and recommendations on topics including clinical evaluation, imaging, endoscopic ultrasound, cyst fluid markers, and pathology.
3. The guidelines are intended to standardize the evaluation and management of CPNs according to morphology and symptoms, while taking into account resources in the Italian healthcare system.
EUS is a new method for diagnosing disorders of the esophagus, stomach, bile and pancreatic ducts, and anal region, as well as intramural lesions of the gastrointestinal tract. It helps with staging of GI cancers and lung cancer by detecting lymph nodes. EUS allows for interventional diagnostic procedures like fine needle aspiration biopsy and drainage, as well as therapeutic procedures. It is well-suited for tumor staging according to the TNM classification by assessing tumor depth and presence of metastases. EUS-guided FNA biopsy provides superior cytopathological diagnosis of primary tumors and nodal metastases compared to other imaging methods.
EUS can be used to stage cancers of the esophagus, stomach, rectum, lung and diagnose pancreatic cancer. It allows evaluation of abnormalities in the GI tract wall and adjacent structures. EUS guided FNA biopsy enables cytopathological diagnosis of cancers and nodal metastases. EUS is well-suited for TNM tumor staging as it can assess depth of tumor penetration, locoregional nodal spread and vascular invasion. It also has applications in diagnosis of cholangiocarcinoma, evaluation of pancreatic cysts and masses, and celiac plexus neurolysis for pain relief.
The document discusses the management of liver metastases from colorectal cancer. It reports on a study that found perioperative chemotherapy with FOLFOX4 improved progression-free survival in patients with resectable liver metastases, especially in those whose metastases were resected. The study established perioperative chemotherapy as the new standard of care for these patients. It also discusses challenges in treating colorectal cancer patients with only liver metastases and strategies for increasing resection rates and long-term survival, including optimizing systemic therapies and utilizing a multidisciplinary team approach.
This document discusses the use of chromoendoscopy and narrow band imaging (NBI) with magnification for detecting and diagnosing squamous cell carcinomas (SCCs) in the esophagus and pharynx. It outlines various dyes used in chromoendoscopy and describes findings on NBI like brownish areas and irregularities in intra-epithelial papillary capillary loops that indicate early SCCs. Studies show NBI has significantly higher detection and diagnostic accuracy rates than white light imaging for SCCs in both locations. NBI classification systems are presented to diagnose SCC depth.
Ntc dr muthusamy bridge to surgery talk final 6 18MUCINGroup
This document discusses endoscopic evaluation and staging of pancreatic cancer. It begins by outlining the algorithm for evaluating suspected pancreatic cancer with CT/MRI and EUS. Key questions after detecting a pancreatic mass include determining resectability and predicting tumor stage. Stages are defined as resectable, borderline, locally advanced, and metastatic based on criteria such as vascular involvement. Examples of EUS images illustrating resectable, locally advanced, and borderline resectable cancers are provided. The document concludes that neoadjuvant therapy is increasingly used for borderline resectable pancreatic cancer and requires durable biliary drainage during treatment.
EUS has revolutionized both the diagnostic and therapeutic aspects of gastroenterology. It combines an endoscope with an ultrasound probe to examine the GI tract walls and nearby structures. EUS is very useful for staging cancers of the esophagus, pancreas, and biliary tract, and is the most sensitive method for distinguishing between benign and malignant pancreatic tumors. EUS also has several important therapeutic roles, including draining pancreatic fluid collections, accessing the biliary tree non-surgically, celiac plexus neurolysis for pancreatic cancer pain relief, and delivering targeted cancer treatments. Recent advances have further increased the diagnostic and therapeutic capabilities of EUS.
Benign Biliary Stricture is a common condition which we encounter during gastro practice. Here we discuss in detail about its diagnosis and management.
CT urography (CTU) is highly accurate for detecting bladder cancer in high-risk patients. A retrospective study of 45 high-risk patients found that CTU had a 97% sensitivity and 80% specificity for bladder cancer detection compared to flexible cystoscopy. Multivariate analysis showed that positive CTU findings were highly significant predictors of bladder cancer diagnosis. The study suggests that in high-risk patients with positive CTU findings, flexible cystoscopy could be omitted and patients referred directly for rigid cystoscopy and potential biopsy or resection. However, the study had some limitations due to the small sample size.
This document discusses treatment options for cancer of the esophagus. It covers staging, endoscopic resection options for early stage cancers, preoperative chemoradiation followed by surgery as standard treatment for locally advanced cancers, and types of surgery and postoperative care. Chemotherapy regimens including cisplatin and fluorouracil provide response rates of 20-30% for metastatic cancers. Overall, the document provides an overview of current guidelines and evidence for endoscopic, surgical, radiation, and chemotherapy approaches to esophageal cancer treatment based on tumor stage.
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi - Gastro...Gastrolearning
Gastrolearning II modulo/7a lezione
Il colangiocarcinoma: Epidemiologia, Fattori di rischio e patogenesi
Prof. D. Alvaro - Università di Roma La Sapienza
Gallstone disease is common, with cholesterol stones forming due to cholesterol saturation and gallbladder dysmotility. Complications include biliary colic, cholecystitis, cholangitis, and pancreatitis. Choledocholithiasis presents with biliary symptoms and jaundice and is treated with ERCP and sphincterotomy. Acalculous cholecystitis occurs in critically ill patients and requires urgent cholecystectomy or percutaneous drainage. Choledochal cysts are congenital anomalies of the biliary tree classified by Todani type and often require surgical excision.
This document provides information on pancreatic adenocarcinoma, including its anatomy, physiology, clinical presentation, investigations, staging, treatment and prognosis. It discusses the exocrine and endocrine functions of the pancreas. It also covers cystic lesions of the pancreas and pancreatic endocrine tumours. The staging and survival rates for pancreatic cancer are presented. Complications of pancreatic surgery and mortality rates at high volume centers are summarized.
Gallbladder disease is common, affecting around 5% of the population. Gallstones are the most common cause of gallbladder disease and occur more often in women, with increasing age. Symptoms include biliary colic, acute cholecystitis, and in rare cases gallbladder cancer. Treatment options include oral medication, lithotripsy for single stones, and cholecystectomy for symptomatic or complicated cases. Complications can include cholangitis, pancreatitis, and choledocholithiasis requiring ERCP.
This document discusses diseases of the gallbladder and bile ducts. It covers topics like cholecystitis (inflammation of the gallbladder), choledocholithiasis (gallstones in the bile ducts), and cholangitis (infection and inflammation of the bile ducts). Signs, symptoms, diagnostic tests, and treatments are described for various conditions. Risk factors for gallstone formation include obesity, pregnancy, and hereditary conditions. Complications can include perforation or fistula formation. Conditions are typically diagnosed using ultrasound, CT, or ERCP and treated with antibiotics, stone dissolution therapies, or cholecystectomy.
Liver and Gallbladder Surgical PathologyGhie Santos
This document summarizes surgical liver and biliary pathology presented by Dr. Noel C. Santos. It discusses focal liver lesions including tumors and tumor-like lesions of the liver. It also discusses diseases of the gallbladder and bile ducts. Primary and metastatic liver tumors are classified and various pathologies of the liver, bile ducts, and gallbladder are described including hepatocellular carcinoma and cholangiocellular carcinoma.
This document defines various components of the biliary system including bile, bile salts, and bile acids. It describes bile acid metabolism and the enterohepatic circulation. It discusses cholestasis, approaches to diagnosing a patient with cholestasis, and various causes of cholestasis including gallstones. It describes the pathophysiology, risk factors, clinical features, diagnosis, and treatment of gallstone disease. It also discusses other biliary diseases and conditions such as primary sclerosing cholangitis, biliary strictures, and biliary dyskinesia.
Pancreatic cancer is the 10th most common cancer and the 4th leading cause of cancer death. 80% are adenocarcinomas from the exocrine pancreas. Risk factors include smoking, low fruit/vegetable intake, obesity, and family history. Symptoms are nonspecific but include jaundice, weight loss, and pain. Imaging like CT scans and endoscopic ultrasound are used to determine if tumors are resectable in 15-20% of patients. The Whipple procedure removes the pancreas head while distal pancreatectomy removes the body/tail. Adjuvant chemo may be given but 70-80% of patients still recur due to the pancreas' rich blood supply
This document discusses treatment options for colorectal liver metastases, including systemic chemotherapy, surgical resection, chemoembolization, radioembolization, and portal vein embolization. It notes that systemic chemotherapy alone yields a median survival of 18-21 months but can downstage liver metastases to resectability in 20-25% of cases, resulting in a 5-year survival of 33%. Chemoembolization and radioembolization clinical trials demonstrate median survival ranges of 9-21 months. The document emphasizes the importance of the interventional oncologist in multidisciplinary care to increase the potential for curative resection through downstaging or portal vein embolization.
Il trattamento chirurgico del colangiocarcinoma - Gastrolearning®Gastrolearning
Gastrolearning II modulo/8a lezione
Il trattamento chirurgico del colangiocarcinoma
Prof. Gian Luca Grazi - Hepato-Biliary-Pancreatic Surgery National Cancer Institute Regina Elena, Roma
Laparoscopy and laparoscopic ultrasound improve staging of pancreatic cancer and help determine resectability, avoiding unnecessary surgery. Laparoscopic techniques can treat some benign and malignant pancreatic tumors, as well as pancreatic trauma, pseudocysts, and provide palliative bypass when cancer is unresectable, with benefits of less morbidity, mortality, and shorter hospital stays compared to open surgery.
This document discusses the debate around whether endovascular or surgical interventions should be the first option for treating critical limb ischemia in the lower extremities. It presents data on patency rates from studies comparing percutaneous angioplasty and stenting to femoral-popliteal bypass. It also summarizes studies reporting outcomes of endovascular and surgical procedures for various levels of the leg vasculature. The overall conclusion is that an endovascular-first approach is reasonable for appropriately selected patients, as it is not associated with worse outcomes compared to initial surgery.
The surgical management of gastroesophageal cancerforegutsurgeon
This document discusses surgical techniques for treating gastroesophageal cancers and early stage esophageal adenocarcinoma. It finds that laparoscopic staging is useful for gastric cancer and laparoscopic resection may provide benefits over open surgery. While D2 lymphadenectomy provides more thorough staging, it also carries higher risks than D1 with no clear survival benefit. For early esophageal cancers, esophagectomy carries a small but definite risk of recurrence compared to endoscopic mucosal resection, but laparoscopic esophagectomy outcomes are similar to open surgery.
Staging and Surgical Management of Pancreatiic Canceru.surgery
This document discusses staging and surgical management of pancreatic cancer. It covers staging techniques like CT, endoscopic ultrasound, laparoscopy and biomarkers. CT is good for predicting resectability but not lymph node status. Endoscopic ultrasound is useful for diagnosis and staging. Laparoscopy can detect small volume disease and changes management in 10-15% of cases. Extended resections, portal vein resection and pylorus-preserving pancreaticoduodenectomy are discussed. Reconstruction techniques after resection include pancreaticojejunostomy. Drains and stents may not provide benefits while octreotide could help for high-risk anastomoses. Outcome depends on tumour type and quality of life is improved at high-volume
Nuclear medicine techniques such as PET and scintigraphy provide functional information that can aid in early diagnosis and management of gastrointestinal diseases. PET-CT in particular allows more accurate tumor assessment by distinguishing scar tissue from residual tumor. PET has high sensitivity and specificity for detecting colorectal cancer recurrence and liver metastases. It also has advantages over CT and MRI for staging esophageal and pancreatic cancers by identifying unsuspected distant metastases. However, PET has limitations such as lower sensitivity for small or mucinous tumors and potential false positives from inflammation.
This document summarizes the management of gallbladder carcinoma and associated controversies. It discusses presentations of gallbladder cancer, diagnosis and staging techniques including imaging and tumor markers. It covers staging systems from AJCC and NCCN as well as management guidelines. Controversies discussed include the extent of liver and lymph node resection, the role of laparoscopy versus open surgery, PET-CT, CBD excision, neoadjuvant therapy, and HPD. Issues related to incidental gallbladder cancer are also summarized, including timing and extent of reoperation after index cholecystectomy. The role of adjuvant therapy is discussed.
This document discusses the 25-year treatment of a patient with metastatic carcinoid tumor to the liver through various interventions including surgery, chemotherapy, radiation therapy, and more. It provides details on the progression of the disease and treatments over time, highlighting that interventional oncology can provide durable therapies to control liver metastases when integrated with other treatments. Combining liver-directed and systemic therapies may further improve long-term outcomes but requires additional study.
This document summarizes key information about cancer of the esophagus:
1) The esophagus spans from the cricopharyngeus to the GE junction. Esophageal cancer risk factors include smoking, alcohol, caustic injury, HPV infection, obesity, and Barrett's esophagus.
2) The most common types of esophageal cancer are squamous cell carcinoma (SCC) in the upper two-thirds and adenocarcinoma in the lower third. Distant metastases are most common in the lung, liver, and bone.
3) Treatment options discussed include surgery, chemotherapy, radiation therapy, and their combinations in neoadjuvant and adjuvant settings. Several large randomized controlled trials
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1. ENDOSCOPIC DIAGNOSIS AND
MANAGEMENT OF BILE DUCT
CANCERS
Jason Klapman, M.D.Jason Klapman, M.D.
Associate Professor of MedicineAssociate Professor of Medicine
Director of EndoscopyDirector of Endoscopy
Gastrointestinal Tumor ProgramGastrointestinal Tumor Program
Moffitt Cancer CenterMoffitt Cancer Center
2. Outline
Pre-Procedure EvaluationPre-Procedure Evaluation
Imaging studiesImaging studies
Determine ResectabilityDetermine Resectability
Tissue DiagnosisTissue Diagnosis
ERCP-cyto/biopsiesERCP-cyto/biopsies
EUS with Fine Needle AspirationEUS with Fine Needle Aspiration
Cholangioscopic directed biopsiesCholangioscopic directed biopsies
Endoscopic TreatmentEndoscopic Treatment
StentingStenting
Endoscopic directed therapyEndoscopic directed therapy
3. Bismuth Classification
Type 1 (Extrahepatic)Type 1 (Extrahepatic)
25%25%
Type II-IVType II-IV
Klatskin’s TumorsKlatskin’s Tumors
60-65%60-65%
Intrahepatic CCAIntrahepatic CCA
10-15%10-15%
4. Klatskin’s Tumor
Definition- Perihilar tumors that involve the- Perihilar tumors that involve the
bifurcation of the hepatic ductbifurcation of the hepatic duct
Represent 60-65% of all CCARepresent 60-65% of all CCA
5-year survival 15-30%5-year survival 15-30%
Resectable in only 30%Resectable in only 30%
Palliation mainstay of treatmentPalliation mainstay of treatment
5. Criteria For Unresectability
Medical contraindications to surgeryMedical contraindications to surgery
N2 nodal disease or distant liver metastasesN2 nodal disease or distant liver metastases
Vascular invasionVascular invasion
Extra-hepatic adjacent organ invasionExtra-hepatic adjacent organ invasion
Presence of disseminated diseasePresence of disseminated disease
LOCAL UNRESECTABILITYLOCAL UNRESECTABILITY
6. Local Unresectability
Involvement of bilateral hepatic duct up toInvolvement of bilateral hepatic duct up to
secondary radicles bilaterally, encasement/secondary radicles bilaterally, encasement/
occlusion or PV/ HAocclusion or PV/ HA
Determined by Imaging studiesDetermined by Imaging studies
CTscan, MRI/MRCP, ERCP and EUSCTscan, MRI/MRCP, ERCP and EUS
Surgical ExplorationSurgical Exploration
11. MRCP
TARGETING THERAPYTARGETING THERAPY
Hintze et al GIE 2001
Evaluated MRCP to aid in unilateral stentEvaluated MRCP to aid in unilateral stent
placement for Klatskin’s Tumor’splacement for Klatskin’s Tumor’s
Resolution of Bilirubin in 86%Resolution of Bilirubin in 86%
Cholangitis 2/35Cholangitis 2/35
Freeman GIE 2003Freeman GIE 2003
CT scan or MRCP to selectively targetCT scan or MRCP to selectively target
drainage using metallic stentsdrainage using metallic stents
Palliation in 77% of patientsPalliation in 77% of patients
14. Brush Cytology in Malignant
Biliary Strictures
AuthorsAuthors YRYR PT’sPT’s Ca.Ca. TPTP SeSe SpeSpe PPVPPV NPVNPV
Foutch et alFoutch et al 9191 3030 1717 66 33%33% 100%100% 100%100% 58%58%
Lee et alLee et al 9595 149149 106106 4040 37%37% 100%100% 100%100% 39%39%
Ponchon et alPonchon et al 9595 204204 127127 4545 35%35% 97%97% 96%96% 44%44%
Pugliese et alPugliese et al 9595 9494 6464 3535 54%54% 100%100% 100%100% 50%50%
Glasbrenner et alGlasbrenner et al 9999 7878 5757 3232 56%56% 90%90% 84%84% 43%43%
Mansfield et alMansfield et al 9797 4343 4141 1717 42%42% 100%100% 100%100% 8%8%
Jailwala et alJailwala et al 9999 133133 104104 3131 30%30% 100%100% 100%100% 28%28%
Macken et alMacken et al 0000 106106 6262 3535 57%57% 100%100% 100%100% 62%62%
TotalTotal 837837 578578 241241 42%42% 98%98% 99%99% 43%43%
De bellis et al, GIE 2002
15. ERCP-guided Biopsy of
Malignant Biliary Strictures
AuthorsAuthors YRYR PT’sPT’s Ca.Ca. TPTP SeSe SpeSpe PPVPPV NPVNPV
Kubota et alKubota et al 9292 4141 3232 2626 81%81% 100%100% 100%100% 75%75%
Pugliese et alPugliese et al 9494 5252 3636 1919 53%53% 100%100% 100%100% 48%48%
Ponchon et alPonchon et al 9595 128128 8282 3535 43%43% 97%97% 97%97% 41%41%
Sugiyama et alSugiyama et al 9696 4545 3131 2525 81%81% 100%100% 100%100% 67%67%
Schoefl et alSchoefl et al 9797 103103 5858 3838 65%65% 100%100% 100%100% 69%69%
Jailwala et alJailwala et al 9999 133133 104104 4848 43%43% 90%90% 94%94% 31%31%
TotalTotal 502502 343343 191191 56%56% 97%97% 97%97% 51%51%
De bellis et al, GIE 2002
16. Combined Brush and Biopsy of
Malignant Biliary strictures
AuthorsAuthors YRYR BrushBrush BiopsyBiopsy Brush andBrush and
BiopsyBiopsy
Ponchon et alPonchon et al 9595 33%33% 44%44% 61%61%
Pugliese et alPugliese et al 9595 54%54% 55%55% 61%61%
Schoefl et alSchoefl et al 9797 47%47% 65%65% 70%70%
De bellis et al, GIE 2002
17. EUS-guided FNA
Useful in obtaining a diagnosis in pt’s withUseful in obtaining a diagnosis in pt’s with
negative ERCP cytology and high index ofnegative ERCP cytology and high index of
suspicionsuspicion
Fritscher-Ravens et al.Fritscher-Ravens et al. GIE 2000GIE 2000
9/10 with Hilar lesions obtained a Tissue9/10 with Hilar lesions obtained a Tissue
DiagnosisDiagnosis
2 patients had LN’s aspirated2 patients had LN’s aspirated
Eloubeidi et al.Eloubeidi et al. Clin Gastro and Hepatol 2004Clin Gastro and Hepatol 2004
25/28 pts underwent FNA25/28 pts underwent FNA
• 18 CCA, 4 benign and 3 FN18 CCA, 4 benign and 3 FN
• Impacted Pt management in 84%Impacted Pt management in 84%
20. Cholangioscopy with biopsies
Single-operator system introduced in 2005Single-operator system introduced in 2005
Indeterminate biliary stricturesIndeterminate biliary strictures
Ramchandani et al. GIE 2011Ramchandani et al. GIE 2011
36pts (22 malignant) underwent36pts (22 malignant) underwent
cholangioscopy with biopsiescholangioscopy with biopsies
Accuracy was 89% for differentiatingAccuracy was 89% for differentiating
malignant vs. non-malignant stricturesmalignant vs. non-malignant strictures
Accuracy in pt’s with previous inconclusiveAccuracy in pt’s with previous inconclusive
ERCP brushings or biopsies was 82%ERCP brushings or biopsies was 82%
21. Cholangioscopy with biopsies
Draganov et al. GIE 2012Draganov et al. GIE 2012
Compared conventional cytologyCompared conventional cytology
brushings and biopsies andbrushings and biopsies and
cholangioscopic biopsies on 26cholangioscopic biopsies on 26
patients (17 cancer)patients (17 cancer)
Cholangioscopic biopsies significantlyCholangioscopic biopsies significantly
higher accuracy (84.6% vs. 58% vs.higher accuracy (84.6% vs. 58% vs.
38.5 %)38.5 %)
22. Diagnostic algorithm for tissue
diagnosis
ERCP brushings/biopsy- if negativeERCP brushings/biopsy- if negative
EUS with FNA- if negativeEUS with FNA- if negative
ERCP with cholangioscopic guidedERCP with cholangioscopic guided
biopsies-if negative??biopsies-if negative??
DDx- benign vs. malignantDDx- benign vs. malignant
Consider repeat ERCP withConsider repeat ERCP with
cholangioscopic biopsies if mass ischolangioscopic biopsies if mass is
seen and clinical suspicion highseen and clinical suspicion high
24. Are two stents better than one to
obtain resolution of jaundice?
Technical issuesTechnical issues
Feasibility of placing 2 stentsFeasibility of placing 2 stents
Risk of cholangitis of undrained biliaryRisk of cholangitis of undrained biliary
segment if unable to place 2 stentssegment if unable to place 2 stents
MRCP useful to target drainageMRCP useful to target drainage
R hepatic duct 1cmR hepatic duct 1cm
L hepatic duct 3cmL hepatic duct 3cm
Drainage of 25% of liver resolves jaundiceDrainage of 25% of liver resolves jaundice
L lobe-35%, R-lobe-55-60%, caudate lobe 10-L lobe-35%, R-lobe-55-60%, caudate lobe 10-
15%15%
25. Unilateral vs. Bilateral Stenting
Chang et al., GIE 1998Chang et al., GIE 1998
Evaluated the outcomes of 98 patients withEvaluated the outcomes of 98 patients with
unresectable CCA who underwent unilateral orunresectable CCA who underwent unilateral or
bilateral stentingbilateral stenting
Retrospective reviewRetrospective review
Patients with bilateral drainage had aPatients with bilateral drainage had a
significant survival advantage 225 vs. 80significant survival advantage 225 vs. 80
daysdays
Cholangitis 11% (32% in pts with un-Cholangitis 11% (32% in pts with un-
drained segments)drained segments)
26. Unilateral vs. Bilateral Stenting
De Palma et al. GIE 2001De Palma et al. GIE 2001
Compared unilateral vs. bilateral hepatic ductCompared unilateral vs. bilateral hepatic duct
drainagedrainage
157 patients randomly assigned prospectively157 patients randomly assigned prospectively
Unilateral group had higher stent insertionUnilateral group had higher stent insertion
success and less complicationssuccess and less complications
Successful drainage, survival comparable inSuccessful drainage, survival comparable in
both groupsboth groups
ConclusionConclusion:bilateral stenting not justified and may:bilateral stenting not justified and may
increase complicationsincrease complications
27. Unilateral vs. Bilateral Stenting
De Palma et al. GIE 2003De Palma et al. GIE 2003
Evaluated Unilateral metal stent placement forEvaluated Unilateral metal stent placement for
hilar obstruction in 61patientshilar obstruction in 61patients
All patients underwent MRCP pre-procedureAll patients underwent MRCP pre-procedure
Stent insertion 59/61Stent insertion 59/61
Successful biliary drainage in 59/61Successful biliary drainage in 59/61
Cholangitis 5%Cholangitis 5%
Median stent patency of 169 daysMedian stent patency of 169 days
28. Unilateral vs. Bilateral Stenting
Naitoh et al. J Gastroenterol Hep 2009Naitoh et al. J Gastroenterol Hep 2009
Retrospective series of 46 patientsRetrospective series of 46 patients
showed better outcomes with bilateral vs.showed better outcomes with bilateral vs.
unilateral stentingunilateral stenting
Improved stent patency bilateral groupImproved stent patency bilateral group
488 vs. 210 days for unilateral group488 vs. 210 days for unilateral group
(p=.009)(p=.009)
30. Plastic Stents Metal Stents
Median Patency 3-Median Patency 3-
5mos5mos
Average diameter isAverage diameter is
10Fr (3.3mm)10Fr (3.3mm)
Stent change q3mos.Stent change q3mos.
Median Patency 6-Median Patency 6-
8mos8mos
Self expandable up toSelf expandable up to
30Fr (10mm)30Fr (10mm)
PermanentPermanent
31. Plastic vs. Metal?
Life ExpectancyLife Expectancy
Quality of LifeQuality of Life
CostCost
Physician ExpertisePhysician Expertise
No Difference in Survival
33. New technology
Cook Zilver635Cook Zilver635®® systemsystem
UUncovered metal stent deployment system that uses ancovered metal stent deployment system that uses a
6fr deliver catheter6fr deliver catheter
Sizes 6,8 and 10mm and 4,6 and 8cm lengthSizes 6,8 and 10mm and 4,6 and 8cm length
Advantages over conventional SEMSAdvantages over conventional SEMS
Less need to dilate Hilar strictures as the introducerLess need to dilate Hilar strictures as the introducer
system is much smallersystem is much smaller
Allows simultaneous deployment of bilateral stentsAllows simultaneous deployment of bilateral stents
through the scopethrough the scope
• This allows easier access in the future to eachThis allows easier access in the future to each
side of the biliary system as they are side by sideside of the biliary system as they are side by side
and not in the Y configurationand not in the Y configuration
34. Zilver635® 6F system
Waxman et al. GIE 2010Waxman et al. GIE 2010
49 stents placed in 16 patients49 stents placed in 16 patients
Technical success was 100%Technical success was 100%
Side by Side deployment achieved in all 10Side by Side deployment achieved in all 10
cases attemptedcases attempted
Additional transpapillary stenting wasAdditional transpapillary stenting was
performed for future accessperformed for future access
Conclusion- works great but would like longerConclusion- works great but would like longer
lengths that may bridge papillalengths that may bridge papilla
38. Tips and tricks for deployment
Spray Pam for lubricationSpray Pam for lubrication
Consider a small sphincterotomyConsider a small sphincterotomy
Although different sizes exist, try and placeAlthough different sizes exist, try and place
largest diameter stent when possiblelargest diameter stent when possible
When stents unable to bridge papilla,When stents unable to bridge papilla,
consider deploying shorter 2consider deploying shorter 2ndnd
stents withinstents within
stents to allow for future access for re-stents to allow for future access for re-
interventionintervention
39. Outline
Pre-Procedure EvaluationPre-Procedure Evaluation
Imaging studiesImaging studies
Determine ResectabilityDetermine Resectability
Tissue DiagnosisTissue Diagnosis
ERCP-cyto/biopsiesERCP-cyto/biopsies
EUS with Fine Needle AspirationEUS with Fine Needle Aspiration
Cholangioscopic directed biopsiesCholangioscopic directed biopsies
Endoscopic TreatmentEndoscopic Treatment
StentingStenting
Endoscopic directed therapyEndoscopic directed therapy
41. ERCP-guided PDT
Dumoulin et al.Dumoulin et al. GIE 2003GIE 2003
PDT and Metal stent as palliation forPDT and Metal stent as palliation for
unresectable Klatskin’s tumorunresectable Klatskin’s tumor
24 patients vs. 20 controls24 patients vs. 20 controls
Median survival 9.9mos vs. 5.6mosMedian survival 9.9mos vs. 5.6mos
Ortner et al.Ortner et al. Gastro 2003Gastro 2003
Prospective randomized trial of PDT +stentingProspective randomized trial of PDT +stenting
vs. stenting alone in Klatskin’s tumorvs. stenting alone in Klatskin’s tumor
20 patients vs. 19 controls20 patients vs. 19 controls
Median Survival PDT group 493 vs.98 daysMedian Survival PDT group 493 vs.98 days
42. ERCP-guided PDT
Zoepf et al. Am J of Gastro 2005Zoepf et al. Am J of Gastro 2005
Randomized 32 pt’s to either PDT/stenting orRandomized 32 pt’s to either PDT/stenting or
stent alone for nonresectable CCAstent alone for nonresectable CCA
Photosan-3Photosan-3
9/16 received 2 PDT sessions, 1 pt 3 sessions9/16 received 2 PDT sessions, 1 pt 3 sessions
Median survival of PDT group wasMedian survival of PDT group was 21mos21mos
vs. 7mosvs. 7mos..
3/16 (PDT) developed cholangitis/infected3/16 (PDT) developed cholangitis/infected
biloma’sbiloma’s
43. ERCP-guided RFA
Steel et al. GIE 2011Steel et al. GIE 2011
22 patients (16 pancreatic and 6 CCA)22 patients (16 pancreatic and 6 CCA)
Deployment of RFA catheter successful inDeployment of RFA catheter successful in
21/2221/22
SEMS placed in all patientsSEMS placed in all patients
End point was safety at 30 and 90 daysEnd point was safety at 30 and 90 days
Endobiliary RFA treatment appears safeEndobiliary RFA treatment appears safe
Further studies are needed with longerFurther studies are needed with longer
durationduration
44. Summary
M e t a l v s P la s t ic
U n ila r e r a l v s B ila t e r a l s t e n t in g
D ia g n o s t ic
D ia g n o s t ic
C h o la n g io s c o p y w it h B io p s ie s
N o n - d ia g n o s t ic
E R C P v s . E U S f o r d ia g n o s is
M R C P
R e f e r r a l f o r E R C P
U n r e s e c t a b le
S u r g e r y
P o t e n t ia lly r e s e c t a b le
P R E S U M E D K L A T S K I N T U M O R
45. Conclusion
Cholangiocarcinoma still a challenge to diagnoseCholangiocarcinoma still a challenge to diagnose
Improved technology including EUS/FNA andImproved technology including EUS/FNA and
cholangioscopic directed biopsies have greatlycholangioscopic directed biopsies have greatly
improved yield in indeterminate stricturesimproved yield in indeterminate strictures
Bilateral stenting may be preferred when possibleBilateral stenting may be preferred when possible
and is now made easier with the Zilver635and is now made easier with the Zilver635®® 6f6f
deployment system which allow simultaneousdeployment system which allow simultaneous
bilateral deploymentbilateral deployment
Always use MRCP as a roadmap before ERCPAlways use MRCP as a roadmap before ERCP
Never place uncovered metal stents without aNever place uncovered metal stents without a
prior diagnosisprior diagnosis
Editor's Notes
Add references
Cholangitis occurs historically in 20-40%
Unclear about added effects of brush and biopsy, pre/post stricture dilation, number of brushings obtained and location of stricture
Atleast 3 specimens
Bottom line- Obtain tissue by using 2 methods to increase the yield
Tissue rates higher for CCA than Pancreatic cancer
25% of liver drained to normalize bilirubin
Left Liver drains 35%, R liver 55-60% and 10-15% drained by the caudate lobe. R hepatic duct is 1cm L hepatic duct 3cm in length
No diff of which duct is drained Polydorou in 1989 showed this
Flawed study
Stent occlusion rates differs from plastic to metal
Cholangitis stopped after giving post treatment antibiotics for 14 days