Endotherapy ofchronic pancreatitisDr Chirayu Chokshi
EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FO...
DIAGNOSIS                     ENDOSONOGRAPHY HIGHLY                    91-100%SENSITIVE                    EUS FNA :LOW RI...
EUS, MRCP OR BOTH ?   EUS   DETECTION OF DEBRIS IN COLLECTION   CHANGES OF EARLY CHRONIC/CHRONIC PANCREATITIS   RULE OUT P...
EUS, MRCP OR BOTH ?    MRCP    MPD ANATOMY ESP.DOMINANT DUCTAL STRICTURE    ,MPD OBSTACLE    RUPTURE OF MPD    COMMUNICATI...
EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FO...
2007
WHEN SURGERYPEARLS:1.Successful TRIAL OF ENDOSCOPIC TREATMENT BEFORE SURGERY2.DILATED DUCTAL SYSTEM AND FAILED MEDIAL AND ...
Pain in chronic pancreatitis:     Surgical options:         MPD        DILATED DUCT                          NON DILATED  ...
SURGERY : STANDARD ,TIME TESTED TREATMENT                                         VARIABLE  RESULTS OF SURGERY:           ...
BEST CANDIDATE FOR ENDOSCOPIC TREATMENT:STRICTURE IN PANCREATIC HEAD WITH ‘UPSTREAM DILATATION’Cremer deveiere.Stenting in...
Plastic stents for MPD strictures:AUTHOR YR NO STENT F/UP EARLY PAIN RELIEF SUST.RELIEF OPERATED %Cremer 1991 75 10       ...
EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FO...
ERCP FOR PAIN IN CHRONIC PANCREATITISPANCREATIC SPHINCTEROTOMY           MINOR PAPILLA DRAINAGE IN P.DIVISIUM             ...
Endotherapy of pancreatic stones:Large stonesStone above stricture  Dormia  Baloon extarction  Mech litho.ESWL  Balloon sp...
VIDEO COURTESY BY DR V RATHOD
MPD DRAINAGE SHOULD BE PLANNED EARLY IN COURSEOF CALCIFYING CP         STONES 18%         STRICTURES 47%         STONE AND...
Pancreatic stone management :Small , 5mm non calcific stones can be removed with ERCP                                   J ...
for pain in calcifying CP                                     ESWL:                                  First line mxCOMPLETE...
Take home message:ESWL alone or ERCP combined should be doneearly in course of painful CPDelahaye,J Deveiere Long term cli...
EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FO...
DEFINITIONS OF PANCREATIC FLUID COLLECTIONCHRONIC PSEUDOCYST:COLLECTION OF PANCREATIC JUICE ENCLOSED BYWALL OF FIBROUS OR ...
CHRONIC PSEUDOCYSTS DUE TO ALCOHOL                                                                                        ...
CT SCAN IS MANDATORY                        FOR PLANNING     THERAPY OF PANCREATIC PSEUDOCYST     SENSITIVITY 82%-100%    ...
MX OPTIONS: ENDOSCOPIC RX : Create an alternative                    correct duct disruption CYSTOENTERAL drainage route  ...
CT SCAN                   Prospective series of 50 pts :endoscopic drainage                                           poss...
INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTSCOMPLICATED PANCREATIC PSEUDOCYSTS [1 CRITERION SUFFICE...
INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTSSYMTOMATIC PANCREATIC PSEUDOCYSTSSATIETYPAINN AUSEA VOM...
PREREQUISITE FOR ENDOSCOPIC DRAINAGE     DISTANCE OF PSEUDOCYST TO THE GUT WALL LESS     THAN 1 CM    LOCATION OF TRANSMUR...
6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS
6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS       Pseudocyst drainage by gastroscope
ENDOSCOPIC DRAINAGE :COMPLICATIONS                                 5-16%                       MORE IN CASE OF NECROSIS   ...
Take home message: endoscopic treatment only whenSingle MPD stoneSingle stricture in MPDSingle stone and strictureEarly Pa...
Endoscopic pancreatic necrosectomy:Limited in its use in centres of expertise that deal with pancreaticnecrosis day in and...
Can is definitely not should !!!
Endotherapy in Chronic Pancreatitis
Endotherapy in Chronic Pancreatitis
Endotherapy in Chronic Pancreatitis
Endotherapy in Chronic Pancreatitis
Endotherapy in Chronic Pancreatitis
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Endotherapy in Chronic Pancreatitis

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Endotherapy in Chronic Pancreatitis

  1. 1. Endotherapy ofchronic pancreatitisDr Chirayu Chokshi
  2. 2. EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEFMANAGEMENT OF NON COMMUNICATING PSEUDOCYST
  3. 3. DIAGNOSIS ENDOSONOGRAPHY HIGHLY 91-100%SENSITIVE EUS FNA :LOW RISK OF SEEDLING POORSPECIFICITY OPERATOR DEPENDENT WITHOUT NOT AVAILABLE BX
  4. 4. EUS, MRCP OR BOTH ? EUS DETECTION OF DEBRIS IN COLLECTION CHANGES OF EARLY CHRONIC/CHRONIC PANCREATITIS RULE OUT PSEDOANEURYSM WALL VESSELS AND SELECTION OF SITE r/o mass in pancreasEndo. Treatment for chr pancreatitis,timing,duration and type of inteVrentionThai Nguyen-Tang,Jean Marc Dumonceau.2010 Clinical Gastroenterology.
  5. 5. EUS, MRCP OR BOTH ? MRCP MPD ANATOMY ESP.DOMINANT DUCTAL STRICTURE ,MPD OBSTACLE RUPTURE OF MPD COMMUNICATION WITH COLLECTION ERCP ? IF MRCP NOT CONCLUSIVE/NOT DONE BEFORE DRAINAGE OF COLLECTION THOUGH SOMETIMES DIFFICULTEndo. Treatment for chr pancreatitis,timing,duration and type of inteventionThai Nguyen-Tang,Jean Marc Dumonceau.2010 Clinical Gastroenterology.
  6. 6. EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEFMANAGEMENT OF NON COMMUNICATING PSEUDOCYST
  7. 7. 2007
  8. 8. WHEN SURGERYPEARLS:1.Successful TRIAL OF ENDOSCOPIC TREATMENT BEFORE SURGERY2.DILATED DUCTAL SYSTEM AND FAILED MEDIAL AND ENDOSCOPIC TREATMENT3.CANCER SUSPICION4.PSEUDOCYST NOT AMENABLE TO ENDOSCOPIC TREATMENT CHRONIC PANCREATITIS:ASIA PACIFIC CONSENSUS REPORT: J OF GASTRO AND HEPATO.2002:17.508-518 R TANDON,P GARG,NOBUHIRO SATO
  9. 9. Pain in chronic pancreatitis: Surgical options: MPD DILATED DUCT NON DILATED FOCAL INFLAMM.MASS RESECTION- DISTAL PANCREATECTOMY PRESENT ABSENT HEAD RESECTION DRAINAGERESECTION +DRAINAGE
  10. 10. SURGERY : STANDARD ,TIME TESTED TREATMENT VARIABLE RESULTS OF SURGERY: PATIENT SELECTION TYPE AND EXTENT OF SURGERY VARIABLE F/UP SPONT.PAIN RELIEF AFTER DZ BURNOUTWHY ENDOSCOPIC TRAETMENT? LESS INVASIVE SHORT RESULTS COMPARABLE TO SX PREDICTS OUTCOME AFTER SX SX ALWAYS POSSIBLE AFTER FAILED ENDOTHERAPY
  11. 11. BEST CANDIDATE FOR ENDOSCOPIC TREATMENT:STRICTURE IN PANCREATIC HEAD WITH ‘UPSTREAM DILATATION’Cremer deveiere.Stenting in CP:Results of long term fup of 76 pts.ENDOSCOPy 1991:23:171-176
  12. 12. Plastic stents for MPD strictures:AUTHOR YR NO STENT F/UP EARLY PAIN RELIEF SUST.RELIEF OPERATED %Cremer 1991 75 10 37 94% na 15Ponchon 1995 23 10 14 74% 52 15Smits 1995 49 10 34 82% 82% 6Binmoeller1995 93 5/7/10 58 74% 65% 26Morgan 2003 25 5/7/8.5 na 65% na naVitale 2004 89 5/7/10 43 83% 68% 12Eleftheriades ‘05 100 8.5/10 69 70% 62% 4%Ishiara 2006 20 10 21 95% 90% naWeber 2007 17 all 24 89% 83% na Large pancreatic stents are commonly used After definitive stent removal , 27-38% have pain relapse in 2.1-3.8 yrs Pain relapse treated with stenting Short term pain relief 70-94% Long term pain relief 52-82%
  13. 13. EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEFMANAGEMENT OF NON COMMUNICATING PSEUDOCYST
  14. 14. ERCP FOR PAIN IN CHRONIC PANCREATITISPANCREATIC SPHINCTEROTOMY MINOR PAPILLA DRAINAGE IN P.DIVISIUM RELIEF OF DUCTAL OBSTRUCTION STRICTURE REMOVAL OF OBSTRUCTED DILATATION DUCTAL STONES BALLOON/BOUGIE/ ESWL/MECH.LITHO STENTS EUS GUIDED :PANCREATICOGASTROSTOMY PANCREATICODUODENOSTOMY COELIAC AXIS BLOCK
  15. 15. Endotherapy of pancreatic stones:Large stonesStone above stricture Dormia Baloon extarction Mech litho.ESWL Balloon sphincteroplasty of papilla
  16. 16. VIDEO COURTESY BY DR V RATHOD
  17. 17. MPD DRAINAGE SHOULD BE PLANNED EARLY IN COURSEOF CALCIFYING CP STONES 18% STRICTURES 47% STONE AND STRICTURE 32% 51% HAD NO PAIN IN 4.9 YRSDuomoneauque jm,j deviere Endoscopic pancreatic drainage in chronic pancreatitisassociated with ductal stones.long term results.GIEndoscopy 1996:43:547-55Binmoeller ,soehendra Endoscopic pancreatic drainage in CP and a dominant stricture .ENDOSCOPY 1995:27;638-44RoschT,Daniel,Huibregtse Endoscopic rx of CP:multicenter study of 1000 pts.ENDOSCOPY 2000:34;765-71
  18. 18. Pancreatic stone management :Small , 5mm non calcific stones can be removed with ERCP J Deveriare .GIEndoscopy 1996:43:547-55 70-90% stones cannot be extracted without pre ERCP fragmentation Farnbacher ,Schoen schneider.Pancraetic stone ductal in chr pancreatitis. Criteria for treatment intensity and success.GIEndoscopy 20012:56:501-6
  19. 19. for pain in calcifying CP ESWL: First line mxCOMPLETE PAIN RELIEF IN 62% VS 55% after 2yrsCostamagna et al Treatment for painful calcified chronic pancreatitis”ESWLv/sendoscopic Rx:RCTGUT2007:56:545-7OharaTakeuchi et al Single application eswl is the first choice in CCP.AmJgastr 1996:91:1388-94
  20. 20. Take home message:ESWL alone or ERCP combined should be doneearly in course of painful CPDelahaye,J Deveiere Long term clinical outcome in painful CP after endoscopicpancreatic ductal drainageClininc gastr hepatology 2004:2:1096
  21. 21. EUS –MRCP OR BOTH OF THEM?SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETICPATIENT WITH WT LOSSROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEFMANAGEMENT OF NON COMMUNICATING PSEUDOCYST
  22. 22. DEFINITIONS OF PANCREATIC FLUID COLLECTIONCHRONIC PSEUDOCYST:COLLECTION OF PANCREATIC JUICE ENCLOSED BYWALL OF FIBROUS OR GRANULATION TISSUE DUE TO CHRONIC PANCREATITIS INCIDENCE OF PSEUDOCYST AFTER AC PANCREATITIS 5-16% CHR PANCREATITS 20-40% BRADLEY EL A CLINICALLY BASED CLASSIFICATION SYSTEM FOR AC PANCREATITIS.SUMMARY OF INTERNL SYMP ON AC PANCREATTIS 1992 ARCH SURG 1993:128:586-590 BARTHET M BUGALLO M MX OF CYSTS AND PSEUDOCYSTS COMPLICATING CHR PNCREATITIS,A RETRO STUDY 143 PTS. GASTROENTEROLOGY CLINC BBIOL 1993: 17- 2770-276 ELLIOT PANCREATIC PSEUDOCYSTS SURG CLINIC OF N AMERICA 1975:55-339-362
  23. 23. CHRONIC PSEUDOCYSTS DUE TO ALCOHOL 64% ALCOHOL RELATED PANCRETIC PSEUDOCYSTS 56%-78% AETIOLOGY OF PANCREATITIS: GALL STONE 6-36% POST TRAUMATIC OR SURGICAL 3-8% IDIOPATHIC 6-20%SANFEY H JONES PSEUDOCYSTS OF PANCREAS ,A REVIEW OF 143 CASES AM SURG 1994:60:661-668LAWSON LC FROMKES ERCP IN MX OF PANC PSEUDOCSTS AM J SURG 1985-:150:683-686USATOFF V OPERATIVE TREATMENT OFPSEUDOPCYSTS IN CHRONIC PANCREATITIS BR J SURG 2000 :87-1494-1499KOLARS JC PANCREATIC PSEUDOCYSTS ARCH SURG 1990 125:759-763
  24. 24. CT SCAN IS MANDATORY FOR PLANNING THERAPY OF PANCREATIC PSEUDOCYST SENSITIVITY 82%-100% SPECIFICITY 92-94% OVERALL ACCURACY 88-94%HAWES RH ENDOSCOPIC MANAGEMENT OF PSEUDOCYSTT.Rev Gastroenterolo Disord 2003 :3;135-141LEE STALEY PANCREATIC IMAGING BY US/CT SCAN Radiological clinicof N A 1979:17:105-117
  25. 25. MX OPTIONS: ENDOSCOPIC RX : Create an alternative correct duct disruption CYSTOENTERAL drainage route TRANSMURAL DRAINAGE TRANSPAPILLARY DRAINAGEGIE 2009 2004 1999.CURRENT TRENDS IN GASTROENTEROLOGY 2002
  26. 26. CT SCAN Prospective series of 50 pts :endoscopic drainage possible in 98% pts and collection dissapearence in 98% cases with a f/up of 11 monthsPORTAL HT NO PORTAL HT NO DIGESTIVE BULGE DIGESTIVE BULGE LARGE CYST >= 5 CM CYST <5 CMS NO PD COMMUNICATION PD COMMUNICATION EUS GUIDED PROCEDURE TRANSPAPILLARY DRAINAGE TRANSMURAL DRAINAGEBARTHET etal Clinical usefullnesss of the a treatment algorithm f or pancreatic pseudocystG I ENDOSCOPY 2008:VOL 67;245-52
  27. 27. INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTSCOMPLICATED PANCREATIC PSEUDOCYSTS [1 CRITERION SUFFICENT]COMPRESSION OF LARGE VESSELS[CLINICAL SYMTOMSORON CT SCAN] GASTRIC OR DUODENAL OBSTRUCTIONSTENOSIS OF THE CBDINFECTED PSEUDOCYSTH’GE INTO PSEUDO CYTSPANCRETICOPLEURAL FISTULA
  28. 28. INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTSSYMTOMATIC PANCREATIC PSEUDOCYSTSSATIETYPAINN AUSEA VOMITINGUPPER G I BLEEDASYMTOMATIC PANCREATIC PSEUDOCYSTDIAMETER MORE THAN 4 CMS AND EXTRAPANCREATIC COMLN IN PTS WITH CHRONIC ALCOHOLIC PANCREATITISPSEUDOCYTS MORE THAN 5 CMS-UNCHANGED MORPHOLOGY FOR MORE THAN 6 WKS
  29. 29. PREREQUISITE FOR ENDOSCOPIC DRAINAGE DISTANCE OF PSEUDOCYST TO THE GUT WALL LESS THAN 1 CM LOCATION OF TRANSMURAL APPROACH BASED ON MAXIMUM BULGE OF THE PSEUDOCYST TO THE ADJACENT WALLRossea e ,Pancreatic Pseudocyst in Chronic pancreatitis.endoscopicand surgical treatment Dig surg 2003:20:397-406Monkemuller ,kahl.Endoscopic therapy of chronic pancreatitis. Dig dz 2004:22:280-291Smiths ME,RauwsTytgat .The efficacy of endoscopic treatment of pancreatic pseudocysts. Gastrointestinal endoscopy 1995:42-202-207Monkemuller KE Baron Morgan.Transmural Drainage of pancreatic fluid collection usingseldinger technique.Gastrointestinal Endoscopy 1998:48:195-200
  30. 30. 6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS
  31. 31. 6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS Pseudocyst drainage by gastroscope
  32. 32. ENDOSCOPIC DRAINAGE :COMPLICATIONS 5-16% MORE IN CASE OF NECROSIS BLEEDING: 8-10% -PSEUDOANEURYSM - GASTRIC DUODENAL VESSEL RUPTURE - ENLARGED COLLATERALS- INFECTION:less than 5% in clear pseudocysts Retroperitoneal perforation Stent migration Stent induced ductal changesJ GISURGERY 2008,PANCREAS 2008,GIE 2004
  33. 33. Take home message: endoscopic treatment only whenSingle MPD stoneSingle stricture in MPDSingle stone and strictureEarly Pancreas divisiumPseudocyst with clear contents or minimal debris
  34. 34. Endoscopic pancreatic necrosectomy:Limited in its use in centres of expertise that deal with pancreaticnecrosis day in and outInsufficient data to recommend a particular techniqueThough included in 10-15 guidelines,,,level of evidence supportingrecommendationisnot included WJS loveday BP 2009
  35. 35. Can is definitely not should !!!
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