This document discusses the management of pancreatic fistulas. It defines pancreatic fistulas as leakage of pancreatic fluid resulting from pancreatic duct obstruction, which can be iatrogenic such as from surgery or ERCP, or non-iatrogenic due to conditions like pancreatitis. Initial management involves controlling pancreatic secretions with drain placement or TPN, correcting electrolyte imbalances, and evaluating the pancreatic duct with imaging. Most fistulas close spontaneously with drainage alone. For persistent fistulas, octreotide can help while ERCP with stenting has closure rates over 80%. Surgery is reserved for failures of other methods and involves duct decompression or resection. Risk factors for postoperative fistulas include duct size, texture, jaundice, and
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
Complications of laparoscopic cholecystectomy, by Dr. Bashab Bijoy Roy, PGT,SMC,Dr.Bashab Roy
Laparoscopic cholecystectomy is the standard procedure for gallbladder removal. However, it can come with complications such as bile duct injury, hemorrhage, and retained stones if not performed carefully. Achieving the "critical view of safety" prior to cystic duct division and obtaining help from an experienced surgeon if needed can help prevent complications. It is also important to convert to an open procedure if the anatomy cannot be clearly visualized or if there is significant bleeding or inflammation. While techniques have improved, the surgeon must take care to correctly identify the biliary anatomy and dissect carefully to safely perform this laparoscopic procedure.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
This document discusses safe laparoscopic cholecystectomy and management of bile duct injuries. It begins with an overview of laparoscopic cholecystectomy and the increased risk of bile duct injury compared to open procedures. It then covers bile duct injury mechanisms, classifications, prevention techniques such as obtaining the critical view of safety, and management strategies whether the injury is recognized intraoperatively or postoperatively. The key messages are that obtaining the correct anatomical views and following established safety procedures can help prevent bile duct injuries, and injuries need to be promptly addressed either by repair or biliary reconstruction to reestablish bile flow.
Diagnosis And Management Of Pancreatic Cystic LesionMyounghwan Kim
The document discusses the diagnosis and management of pancreatic cystic lesions. It is often difficult to differentiate between pseudocysts and cystic neoplasms based on clinical, radiologic, and pathologic features alone. Pseudocysts are the most common type but accurate diagnosis is important to determine proper treatment. Incidental pancreatic cysts found in asymptomatic patients also pose diagnostic challenges. The document provides guidelines on evaluating patients' history, cyst features on imaging, and tumor markers to distinguish between lesion types and recommends appropriate management strategies.
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
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
This document discusses the management of pancreatic fistulas. It defines pancreatic fistulas as leakage of pancreatic fluid resulting from pancreatic duct obstruction, which can be iatrogenic such as from surgery or ERCP, or non-iatrogenic due to conditions like pancreatitis. Initial management involves controlling pancreatic secretions with drain placement or TPN, correcting electrolyte imbalances, and evaluating the pancreatic duct with imaging. Most fistulas close spontaneously with drainage alone. For persistent fistulas, octreotide can help while ERCP with stenting has closure rates over 80%. Surgery is reserved for failures of other methods and involves duct decompression or resection. Risk factors for postoperative fistulas include duct size, texture, jaundice, and
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
Complications of laparoscopic cholecystectomy, by Dr. Bashab Bijoy Roy, PGT,SMC,Dr.Bashab Roy
Laparoscopic cholecystectomy is the standard procedure for gallbladder removal. However, it can come with complications such as bile duct injury, hemorrhage, and retained stones if not performed carefully. Achieving the "critical view of safety" prior to cystic duct division and obtaining help from an experienced surgeon if needed can help prevent complications. It is also important to convert to an open procedure if the anatomy cannot be clearly visualized or if there is significant bleeding or inflammation. While techniques have improved, the surgeon must take care to correctly identify the biliary anatomy and dissect carefully to safely perform this laparoscopic procedure.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
This document discusses safe laparoscopic cholecystectomy and management of bile duct injuries. It begins with an overview of laparoscopic cholecystectomy and the increased risk of bile duct injury compared to open procedures. It then covers bile duct injury mechanisms, classifications, prevention techniques such as obtaining the critical view of safety, and management strategies whether the injury is recognized intraoperatively or postoperatively. The key messages are that obtaining the correct anatomical views and following established safety procedures can help prevent bile duct injuries, and injuries need to be promptly addressed either by repair or biliary reconstruction to reestablish bile flow.
Diagnosis And Management Of Pancreatic Cystic LesionMyounghwan Kim
The document discusses the diagnosis and management of pancreatic cystic lesions. It is often difficult to differentiate between pseudocysts and cystic neoplasms based on clinical, radiologic, and pathologic features alone. Pseudocysts are the most common type but accurate diagnosis is important to determine proper treatment. Incidental pancreatic cysts found in asymptomatic patients also pose diagnostic challenges. The document provides guidelines on evaluating patients' history, cyst features on imaging, and tumor markers to distinguish between lesion types and recommends appropriate management strategies.
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
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
A 42-year-old male presented with abdominal pain for 20 days. Medical history revealed a past diagnosis of pancreatitis. Physical examination found a vague mass palpable in the epigastric and left hypochondrium region. Imaging studies including ultrasound and CT scan identified a cystic structure along the head and tail of the pancreas, with one cyst extending into the mediastinum. The patient underwent a laparotomy with roux-en-y cystojejunostomy to drain a pseudocyst measuring 15x12 cm communicating with a 10x8 cm cyst. Post-operative recovery was uneventful.
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 discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
The document discusses various approaches for managing chronic pancreatitis and pancreatic pseudocysts. It compares EUS, MRCP, and the combination for evaluating chronic pancreatitis. For pain relief in chronic pancreatitis, endotherapy using pancreatic stents is discussed as less invasive than surgery, with short-term relief rates of 70-94% and long-term relief of 52-82%. Early endoscopic treatment of pancreatic stones is recommended to help with long-term pain management. For pancreatic pseudocysts, the document discusses definitions, incidence, imaging with CT, and endoscopic drainage approaches including transmural versus transpapillary based on characteristics like size and communication with the pancreatic duct.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
This document discusses the evaluation and management of cystic tumors of the pancreas. It notes that the most common types are serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Initial imaging includes MRI with MRCP and EUS with FNA to characterize the cyst. Cyst fluid analysis is important to distinguish malignant potential. Small asymptomatic cysts may only need follow up imaging. Surveillance is recommended for certain non-surgical cases, monitoring for changes or malignant progression over multiple years.
This document discusses intestinal anastomosis, which involves creating a connection between intestinal loops or ends. Intestinal anastomosis is commonly performed for elective and emergency cases involving conditions like cancer, infections, or obstructions. The key factors for a successful anastomosis are minimal contamination, good blood supply, and tension-free apposition of the intestinal ends. The document compares hand-sewn and stapled techniques, noting that while staplers are faster, studies have found no difference in outcomes between the two methods. Proper patient factors and surgical technique are more important than the specific method used.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
- Laparoscopic cholecystectomy has become the standard of care for removing the gallbladder.
- The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines in 2010 with recommendations for operating, performing the procedure, and postoperative management.
- The guidelines provide evidence-based recommendations on issues like pre-operative preparation, abdominal access techniques, bile duct assessment, management of acute cholecystitis, gallstone pancreatitis, cirrhosis, anticoagulated patients, porcelain gallbladder, gallbladder polyps, and gallbladder cancer.
This document discusses endoscopic management of obesity, known as endobariatrics. It can be used as primary therapy, bridging therapy before surgery, or revisional therapy after surgery. Primary endoscopic therapies include intragastric balloons, tissue apposition techniques, and nutrient diverting therapies. Secondary endoscopic therapies include transoral outlet reduction, revision obesity surgery procedures, and argon plasma coagulation. Several studies on intragastric balloons and other primary therapies show promising results with 20-50% excess weight loss. Endobariatrics aims to bridge the gap between medical and surgical obesity treatment.
This document discusses principles of bowel anastomosis, including types of anastomoses, indications for anastomoses, pre-operative preparation, intra-operative techniques, post-operative care, complications, and controversies. It covers topics such as hand-sewn versus stapled anastomoses, single versus double layer closure, inversion versus eversion of tissue, and use of abdominal drains and NG tubes. The goal of bowel anastomosis is to successfully rejoin bowel segments through meticulous surgical technique and postoperative management in order to restore intestinal continuity.
Hepatolithiasis: A Dangerous Spectral End Point of Stone DiseaseKETAN VAGHOLKAR
Hepatolithiasis is one of the most complex stone disease of the hepatobiliary system. The disease causes significant damage to the
liver including the chance of developing a cholangiocarcinoma. Though the disease is rampant in East Asian countries isolated cases are seen
even on the Indian subcontinent. Since experience is lacking in our country to treat this uncommon condition awareness of this condition will
enable the surgeon diagnose and develop a proper surgical treatment plan which best suits the patient depending upon the severity of the
disease process. A brief review of the etiopathogenesis, diagnosis and management is presented in this paper.
The document discusses strategies for performing safe laparoscopic cholecystectomy, including obtaining the critical view of safety, using intraoperative cholangiography to help identify biliary anatomy, and employing bailout techniques such as partial or subtotal cholecystectomy if the critical view cannot be achieved to avoid potential bile duct injuries. It also describes error traps that can lead to injuries and strategies surgeons should follow to promote a culture of safety in laparoscopic cholecystectomy.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
The document discusses complications that can occur after a Whipple procedure (pancreaticoduodenectomy), including pancreatic fistulas, delayed gastric emptying, hemorrhage, and diabetes. It provides details on the risk factors, symptoms, diagnosis, and management of each complication. The Whipple procedure has become safer in recent decades but still carries risks of complications in 30-40% of patients.
Pancreatic cystic neoplasm: Definition, Classification, Diagnosis and treatment.Marco Castillo
A brief description of the different pancreatic cystic neoplasms and the pseudocyst, including, eidemiology, classification, risk of malignancy, histology, imaging techniques for diagnosis and treatment.
Alkaline flooding is a chemical EOR method that involves injecting alkaline chemicals like sodium hydroxide, sodium orthosillicate, or sodium carbonate during water or polymer flooding. The chemicals react with certain types of oil to form surfactants that reduce interfacial tension and increase oil production. It works best for oil with relatively high acid content in reservoirs that meet criteria like permeability above 20 md, depth less than 9,000 feet, and temperature below 200 degrees F. A newer variant, alkaline-surfactant-polymer flooding, combines alkali with surfactant and polymer for an effective and less costly form of EOR.
The pancreas is a gland located in the abdomen that produces digestive enzymes and hormones. It is composed primarily of acinar cells that make up the exocrine portion, as well as clusters of endocrine cells called islets of Langerhans. The islets contain alpha, beta, delta, PP, and epsilon cells that produce glucagon, insulin, somatostatin, pancreatic polypeptide, and ghrelin, respectively. Pancreatic diseases include pancreatitis, pancreatic cancer, and diabetes mellitus.
A 42-year-old male presented with abdominal pain for 20 days. Medical history revealed a past diagnosis of pancreatitis. Physical examination found a vague mass palpable in the epigastric and left hypochondrium region. Imaging studies including ultrasound and CT scan identified a cystic structure along the head and tail of the pancreas, with one cyst extending into the mediastinum. The patient underwent a laparotomy with roux-en-y cystojejunostomy to drain a pseudocyst measuring 15x12 cm communicating with a 10x8 cm cyst. Post-operative recovery was uneventful.
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 discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
The document discusses various approaches for managing chronic pancreatitis and pancreatic pseudocysts. It compares EUS, MRCP, and the combination for evaluating chronic pancreatitis. For pain relief in chronic pancreatitis, endotherapy using pancreatic stents is discussed as less invasive than surgery, with short-term relief rates of 70-94% and long-term relief of 52-82%. Early endoscopic treatment of pancreatic stones is recommended to help with long-term pain management. For pancreatic pseudocysts, the document discusses definitions, incidence, imaging with CT, and endoscopic drainage approaches including transmural versus transpapillary based on characteristics like size and communication with the pancreatic duct.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
This document discusses the evaluation and management of cystic tumors of the pancreas. It notes that the most common types are serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Initial imaging includes MRI with MRCP and EUS with FNA to characterize the cyst. Cyst fluid analysis is important to distinguish malignant potential. Small asymptomatic cysts may only need follow up imaging. Surveillance is recommended for certain non-surgical cases, monitoring for changes or malignant progression over multiple years.
This document discusses intestinal anastomosis, which involves creating a connection between intestinal loops or ends. Intestinal anastomosis is commonly performed for elective and emergency cases involving conditions like cancer, infections, or obstructions. The key factors for a successful anastomosis are minimal contamination, good blood supply, and tension-free apposition of the intestinal ends. The document compares hand-sewn and stapled techniques, noting that while staplers are faster, studies have found no difference in outcomes between the two methods. Proper patient factors and surgical technique are more important than the specific method used.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
- Laparoscopic cholecystectomy has become the standard of care for removing the gallbladder.
- The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines in 2010 with recommendations for operating, performing the procedure, and postoperative management.
- The guidelines provide evidence-based recommendations on issues like pre-operative preparation, abdominal access techniques, bile duct assessment, management of acute cholecystitis, gallstone pancreatitis, cirrhosis, anticoagulated patients, porcelain gallbladder, gallbladder polyps, and gallbladder cancer.
This document discusses endoscopic management of obesity, known as endobariatrics. It can be used as primary therapy, bridging therapy before surgery, or revisional therapy after surgery. Primary endoscopic therapies include intragastric balloons, tissue apposition techniques, and nutrient diverting therapies. Secondary endoscopic therapies include transoral outlet reduction, revision obesity surgery procedures, and argon plasma coagulation. Several studies on intragastric balloons and other primary therapies show promising results with 20-50% excess weight loss. Endobariatrics aims to bridge the gap between medical and surgical obesity treatment.
This document discusses principles of bowel anastomosis, including types of anastomoses, indications for anastomoses, pre-operative preparation, intra-operative techniques, post-operative care, complications, and controversies. It covers topics such as hand-sewn versus stapled anastomoses, single versus double layer closure, inversion versus eversion of tissue, and use of abdominal drains and NG tubes. The goal of bowel anastomosis is to successfully rejoin bowel segments through meticulous surgical technique and postoperative management in order to restore intestinal continuity.
Hepatolithiasis: A Dangerous Spectral End Point of Stone DiseaseKETAN VAGHOLKAR
Hepatolithiasis is one of the most complex stone disease of the hepatobiliary system. The disease causes significant damage to the
liver including the chance of developing a cholangiocarcinoma. Though the disease is rampant in East Asian countries isolated cases are seen
even on the Indian subcontinent. Since experience is lacking in our country to treat this uncommon condition awareness of this condition will
enable the surgeon diagnose and develop a proper surgical treatment plan which best suits the patient depending upon the severity of the
disease process. A brief review of the etiopathogenesis, diagnosis and management is presented in this paper.
The document discusses strategies for performing safe laparoscopic cholecystectomy, including obtaining the critical view of safety, using intraoperative cholangiography to help identify biliary anatomy, and employing bailout techniques such as partial or subtotal cholecystectomy if the critical view cannot be achieved to avoid potential bile duct injuries. It also describes error traps that can lead to injuries and strategies surgeons should follow to promote a culture of safety in laparoscopic cholecystectomy.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
The document discusses complications that can occur after a Whipple procedure (pancreaticoduodenectomy), including pancreatic fistulas, delayed gastric emptying, hemorrhage, and diabetes. It provides details on the risk factors, symptoms, diagnosis, and management of each complication. The Whipple procedure has become safer in recent decades but still carries risks of complications in 30-40% of patients.
Pancreatic cystic neoplasm: Definition, Classification, Diagnosis and treatment.Marco Castillo
A brief description of the different pancreatic cystic neoplasms and the pseudocyst, including, eidemiology, classification, risk of malignancy, histology, imaging techniques for diagnosis and treatment.
Alkaline flooding is a chemical EOR method that involves injecting alkaline chemicals like sodium hydroxide, sodium orthosillicate, or sodium carbonate during water or polymer flooding. The chemicals react with certain types of oil to form surfactants that reduce interfacial tension and increase oil production. It works best for oil with relatively high acid content in reservoirs that meet criteria like permeability above 20 md, depth less than 9,000 feet, and temperature below 200 degrees F. A newer variant, alkaline-surfactant-polymer flooding, combines alkali with surfactant and polymer for an effective and less costly form of EOR.
The pancreas is a gland located in the abdomen that produces digestive enzymes and hormones. It is composed primarily of acinar cells that make up the exocrine portion, as well as clusters of endocrine cells called islets of Langerhans. The islets contain alpha, beta, delta, PP, and epsilon cells that produce glucagon, insulin, somatostatin, pancreatic polypeptide, and ghrelin, respectively. Pancreatic diseases include pancreatitis, pancreatic cancer, and diabetes mellitus.
We review the most important articles above the differents Precut techiques: Fistulotomy, Papillotomy and Transpancreatic Sphincterotomy. The techique is safe and effective. And a brief comment about my experience in Fistulotomy, "No Post ERCP Pancreatitis because No touch the papilllary orifice"
I am not a doctor. I am not a medical researcher or lab technician. I have never watched a complete episode of Grey’s Anatomy. But I am a Type 1 Diabetic. I am just one of 25.8 million Americans with Diabetes. We're all kinda experts on managing chronic disease. Because, really, outside of a doctor’s visit every 6 months or so, we’re the ones doing all the work. No one taught us how to do this. A meeting or two with a dietician isn’t enough, the behavioral changes necessary for those with a chronic disease are wholly unsupported in our current medical system. We have to do something. 7 out of 10 deaths in the US are caused by a chronic disease, and between heart disease and diabetes alone we are, as a nation, hemorrhaging money. Many of these conditions are preventable through lifestyle changes that no doctor can write a prescription for. Doctors like to talk about charts and graphs, blood tests and medicine. Let’s start talking about the patient, the person, instead. Let’s make a disease that you have for life something that’s simply managed every day. Let’s get isolated patients together, talking, trading tips and tricks.
The pancreas functions as both an exocrine and endocrine gland. As an exocrine gland, it produces buffers and enzymes that help digest carbohydrates, fats, and proteins in the small intestine. As an endocrine gland, it produces the hormones insulin and glucagon which regulate blood glucose levels. Diseases that can affect the pancreas and its function include diabetes mellitus, pancreatitis, and pancreatic cancer. Diabetes occurs when the pancreas does not produce enough insulin or the body does not properly use insulin.
This document discusses pancreatic diseases and techniques for imaging the pancreas. It lists indications for pancreatic imaging such as assessing congenital pancreatic lesions, equivocal findings, suspected pancreatitis, evaluating pancreatic neoplasm resectability, and biliary or post-traumatic injuries. The techniques discussed include magnetic resonance cholangiopancreatography (MRCP) to image pancreas divisum, interstitial pancreatitis, necrotizing pancreatitis, and using imaging to diagnose high-grade non-Hodgkin's lymphoma of the pancreas.
ERCP (Endoscopic Retrograde Cholangio Pancreatography) is an endoscopic procedure used to diagnose and treat issues in the bile and pancreatic ducts. It involves positioning an endoscope and using x-rays to view the ducts while performing procedures like draining bile ducts, removing gallstones, and placing stents. Potential complications include pancreatitis, bleeding, infection, or perforation. Careful pre- and post-procedure steps like monitoring and antibiotics are important to minimize risks.
This document provides an overview of pancreatic anatomy, physiology, and diseases. It describes the normal anatomy and function of the pancreas, including its exocrine and endocrine components. It then discusses various congenital anomalies and diseases of the pancreas, focusing on acute and chronic pancreatitis. For both conditions, it outlines the etiology, pathology, clinical features, complications, and sequelae. It also describes specific conditions like pancreatic pseudocysts. In summary, the document is a comprehensive review of the pancreas and pancreatic diseases.
ERCP is an endoscopic procedure that combines endoscopy and fluoroscopy to diagnose and treat issues in the duodenum, bile ducts, pancreatic duct, and gallbladder. During ERCP, an endoscope is inserted and a catheter is used to inject radiocontrast dye to identify any blockages. If needed, a wire can enlarge the opening to the bile duct to remove gallstones or perform other procedures like stent placement. Potential but rare complications include infection, pancreatitis, bleeding, and perforation of the GI tract. ERCP requires an experienced physician due to its risks.
This document discusses the pancreas, including its blood supply, lymphatic drainage and role in producing enzymes. It covers congenital abnormalities of the pancreas as well as diseases like acute and chronic pancreatitis. Acute pancreatitis can result from factors like alcoholism, medications or trauma. Chronic pancreatitis is associated with long term damage and can lead to complications like pseudocysts. The document also discusses pancreatic cysts and neoplasms, including serous and mucinous cystadenomas. It provides an overview of pancreatic adenocarcinoma, including risk factors, staging and prognosis.
The document describes the PancreAssist System, a bioartificial pancreas device meant to improve blood glucose control for insulin-dependent diabetics. It consists of pancreatic islets housed within an implantable, reseedable membrane device. In animal studies, the device improved blood glucose control and reduced the need for exogenous insulin without immunosuppression. The development plan is to establish collaborations to further the technology and bring the product to market for brittle diabetics and others with unmet needs.
The pancreas is a 15-20cm long organ located in the retroperitoneum. It has a head, body, and tail. The pancreas contains exocrine tissue that produces enzymes to aid digestion and endocrine tissue clustered in islets of Langerhans that produce hormones like insulin and glucagon. The pancreas develops from dorsal and ventral buds that fuse during embryogenesis. It receives blood supply from various arteries and drains into veins like the portal vein. The pancreas secretes enzymes and bicarbonate to digest nutrients in the small intestine. Removal of the pancreas results in diabetes and digestive issues due to lack of enzymes.
This document summarizes acute pancreatitis, including its definition, causes, symptoms, pathogenesis, complications, diagnostic tests, severity scoring systems, and management. Acute pancreatitis is characterized by inflammation of the pancreas and is most commonly caused by gallstones or alcoholism. It presents with severe epigastric pain and other gastrointestinal symptoms. The pathogenesis involves premature activation of digestive enzymes within the pancreas that can lead to autodigestion. Complications include pseudocysts, abscesses, necrosis, and systemic complications like shock. Diagnosis involves blood tests showing elevated pancreatic enzymes and imaging tests. Severity is assessed using scoring systems like Ranson criteria, APACHE II, and CT severity index. Treatment focuses on fluid
This document discusses acute pancreatitis, including its etiology, pathogenesis, clinical manifestations, diagnosis, and treatment. It defines acute pancreatitis as inflammation of the pancreas induced by the activation of pancreatic enzymes from various causes. The main causes are biliary diseases, alcohol use, hyperlipidemia, and certain drugs. Clinical features include abdominal pain, nausea, vomiting, and fever. Diagnosis is based on symptoms, elevated serum amylase, and imaging findings. Treatment differs between mild and severe acute pancreatitis and focuses on supportive care, pain management, inhibiting pancreatic enzymes, preventing infections and organ failure.
The document discusses diseases of the pancreas, including congenital anomalies, endocrine and exocrine pancreatic diseases, acute and chronic pancreatitis, and pancreatic tumors. It provides details on the causes, pathophysiology, clinical presentation, diagnosis, and treatment of each condition. Key points include the role of gallstones and alcohol as common causes of acute pancreatitis, the use of CT and lab tests to diagnose and determine severity, and supportive care along with surgical or endoscopic interventions for severe cases.
IVU is the radiographic examination of urinary tract including renal parenchyma, calyces and pelvis after intravenous injection of contrast media. Study was carried out at UCMS, Bhairawa, Nepal.
This document provides information on various conventional urinary imaging techniques, including intravenous urography (IVP), micturating cystourethrogram (MCU), and retrograde urethrography (RGU). It discusses the history, indications, contraindications, procedures, and grading of these techniques. IVP involves injecting contrast medium intravenously to visualize the kidneys and urinary tract. MCU involves catheterizing the bladder and filling it with contrast to image the bladder and urethra during voiding. Both techniques can detect abnormalities and evaluate renal function, but have been supplemented by ultrasound, CT, MRI and nuclear medicine due to improved sensitivity, specificity and safety.
This document provides information about an intravenous urogram (IVU) radiographic procedure. It defines an IVU, outlines its indications and contraindications. It describes the contrast media used, patient preparation, and filming sequence. An IVU involves injecting iodine-based contrast media intravenously and then taking a series of x-ray images to outline the urinary system, including the kidneys, ureters and bladder. The document provides details on the procedure steps, potential for reactions to contrast media, and normal radiographic anatomy visualized.
The document describes the procedure of ERCP and T-tube cholangiography, outlining the anatomy, indications, contraindications, equipment, patient preparation, technique, and potential complications. ERCP allows endoscopes and other tools to be passed through the duodenum to visualize and treat the biliary and pancreatic ducts using techniques like sphincterotomy, stone removal, stent placement, and biopsy. A T-tube cholangiogram involves injecting contrast through a surgical T-tube in the bile ducts to image them after gallbladder removal.
This document discusses endoscopy, its history, principles, types, and applications. It describes how endoscopy allows examination of the gastrointestinal tract using an endoscope, a flexible tube with a camera. Key developments in endoscopy are outlined from 1958 to present. The document discusses various endoscopic procedures including upper GI endoscopy, enteroscopy, colonoscopy, and their indications. It provides details on endoscopy techniques, benefits, complications, and images.
Laparoscopy is becoming more widely used in pediatric surgery due to its advantages over open surgery. It can be used diagnostically and for various procedures such as appendectomy, cholecystectomy, splenectomy, hernia repair, and treatment of undescended testes. Some challenges in pediatric laparoscopy include the thin abdominal wall and limited space. Care must be taken with trocar placement and insufflation pressures. Laparoscopy provides benefits like less pain, shorter hospital stays, and quicker recovery times for children. It is an important technique for pediatric surgeons to learn and incorporate into clinical practice.
This document summarizes chronic pancreatitis, including its definition, pathogenesis, clinical manifestations, diagnosis, and treatment options. It provides details on the histopathological changes in chronic pancreatitis, including fibrosis, reduced acinar cells and islets of Langerhans, duct dilation, and pancreatic stones. Medical management focuses on pain control and enzyme supplementation, while surgical options are considered for complications or intractable pain, and include pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, and decompressive procedures.
This document provides information on the hepatobiliary system and various imaging modalities used to evaluate it. It begins with an overview of ultrasound, CT, MRI, ERCP, and nuclear medicine techniques. Key anatomical structures such as the bile ducts and their drainage patterns are described. Various imaging protocols for MRCP, CT cholangiography, and secretin-enhanced MRCP are outlined. Advantages and limitations of different modalities like ERCP are also discussed.
This document provides information about the hepatobiliary system and various imaging modalities used to evaluate it. It begins with an overview of ultrasound, CT, MRI, ERCP, and nuclear medicine techniques. Key anatomical structures such as the gallbladder, bile ducts, and pancreas are described. Various imaging planes and protocols for MRCP and secretin-enhanced MRCP are outlined. ERCP, CT cholangiography, and T-tube cholangiography techniques are also summarized.
Micturating Cystourethrography (MCU) and Retrograde Urethrography (RGU) are imaging techniques used to evaluate the lower urinary tract. MCU involves filling the bladder with contrast and imaging the bladder and urethra during voiding. RGU involves retrograde injection of contrast through the urethra. Both techniques can detect abnormalities of the bladder, urethra, and identify vesicoureteral reflux. Precise technique and imaging in multiple planes are required to fully evaluate the lower urinary tract. Potential complications include infection, contrast reaction, and trauma.
This document discusses imaging of the urinary tract, including KUB (kidneys, ureters, bladder) radiography and intravenous urography (IVU). It provides details on:
- The standard KUB technique using two abdominal x-ray images to outline the kidneys, ureters and bladder.
- The classic IVU procedure involving a series of x-ray images before and after intravenous injection of iodine contrast to visualize the functioning of the kidneys and urinary tract.
- Modifications of IVU for specific situations like urinary obstruction or pregnancy to minimize radiation exposure.
Magnetic Resonance Cholangiopancreatography- MRCPNitish Virmani
Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive MRI technique used to visualize the biliary and pancreatic ducts. It utilizes heavily T2-weighted sequences to provide high signal from fluid-filled structures like the biliary tree and pancreatic ducts. MRCP has largely replaced diagnostic ERCP as it is less invasive and avoids risks of radiation exposure. It is useful for evaluating biliary diseases like cysts, stones, strictures, and pancreatic conditions such as divisum and cancer. With refinements in techniques such as secretin administration, MRCP provides accurate assessment of pancreaticobiliary anatomy and pathology in a safe, noninvasive manner.
The document discusses intravenous urography (IVU), including its definition, history, indications, contraindications, technique, and what to look for in the images. Some key points:
- IVU involves injecting contrast media intravenously and imaging the urinary tract, allowing visualization of the kidneys, ureters, and bladder.
- It was introduced in 1929 but use has declined with the rise of CT, ultrasound and MRI. However, it remains useful for visualizing the pelvicalyceal system.
- The procedure involves obtaining baseline images, injecting contrast, then timed imaging as the contrast passes through the urinary system, sometimes using compression. Findings are assessed for
Radiological importance of intravenous pyelographyPraful9764
An intravenous pyelogram (IVP) is an x-ray imaging procedure that outlines the kidneys, ureters, and bladder after injecting iodinated contrast medium intravenously. It is used to diagnose conditions of the urinary tract like kidney stones, tumors, infections, and structural abnormalities. The procedure involves bowel preparation, intravenous injection of contrast medium, and serial x-ray images over time to visualize the uptake and excretion of the contrast through the urinary tract. Potential risks are mild allergic reactions to the contrast medium, but severe reactions are rare. The images obtained can help diagnose both benign and malignant urinary tract conditions.
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3. Introduction
Pan-Kreas – All Flesh (Rufus Ephesus)
Sir Andrew Watt Kay called pancreas as ‘The Abdominal Tiger’
because of its complex deep retroperitoneal anatomy and
embryogenesis making it difficult to operate.
Pancreatic endoscopy has evolved rapidly since the first reports of
endoscopic Sphincterotomy in 1974 (Claassen & Demling, 1974;
Kawai et al, 1974)
Safrany first performed early endoscopic papillotomy to remove
calculi in the papilla in 1980.
With the recent advances, several endoscopic procedures have
gained a widespread use in pancreatic diseases.
4. Embryology
Begins in 4th wk. of gestation
Develops from two endodermal
primordia
1. Dorsal Bud:
Appears first
Develops into sup. part of head, neck,
body and tail
2. Ventral Bud:
Develops into inf. part of head & uncinate
process
Between 4th to 8th wk., ventral bud
rotates posteriorly, clockwise to
fuse with dorsal bud.
At 8th wk., dorsal and ventral bud
fuse.
5. Anatomy P.A.N.C.R.E.A.S =
Weight- 80 grams (75-125gms)
Length- 8 inch (10-20cms)
pH of pancreatic juice- 8
Total secretions of pancreas- approx. 800cc
Pancreas lies transversely in the
retroperitoneal space.
Lie roughly onto 1st or 2nd lumbar vertebra.
Extending on the right side from duodenum
towards spleen on the left side.
6. Ducts of Pancreas
Begins at the tail as small channel
Herring Bone pattern- joined by no. of tributaries on its way at right angle.
Main pancreatic duct of Wirsung at Major duodenal Papilla (8-10 cm from
pylorus)
Accessory pancreatic duct of Santorini opening at Minor duodenal papilla (6-
8 cm from pylorus)
8. Consist of a control head and a
flexible shaft with a maneuverable
tip.
The head is connected to a light
source via an ‘umbilical’ cord,
through which pass other tubes
transmitting air, water and suction.
The suction channel is used for the
passage of diagnostic tools (e.g.
biopsy forceps) and therapeutic
devices.
9.
10. Types of endoscopes
Tip of a forward viewer endoscope
A side-viewer/ Linear EUS with
cannula protruding from the elevator
12. Ultrasound transducers have been modified so that they can be incorporated into the tip of
flexible endoscopes.
These transducers have the advantage of higher frequency and spatial resolution.
The proximity of the stomach and duodenum to the pancreas allows high-resolution imaging of
the pancreas and eliminates the limits of overlying bowel gas seen in transabdominal
ultrasound.
13. View of normal pancreas on EUS
The echotexture of the pancreatic body is
homogeneous with a fine reticular pattern. The
main pancreatic duct (arrow) is uniform in size
with anechoic margins and without visible side
duct branches. The splenic vein is seen traversing
below the main pancreatic duct
Ventral Anlage: There is distinct difference
in the echotexture of the brighter dorsal
pancreas (D) and the darker ventral
pancreas (V). The aorta (Ao) is traversing
along the ventral pancreas
14. EUS features of chronic pancreatitis: Rosemont's Criteria
Parenchymal criteria Ductal criteria
Major Hyperechoic foci (>2 mm in length/width) MPD calculi (echogenic structure[s] within the
MPD)
Lobularity (≥ 13 contiguous lobules
'honeycombing')
Minor Cyst (anechoic, round/elliptical with or without
septations)
Dilated duct (≥ 3.5 mm in body or >1.5 mm in tail)
Hyperechoic strands (≥ 3 mm in at least 2 different
directions with respect to the imaged plane)
Irregular MPD contour (uneven or irregular
outline and ectatic course)
Dilated side branch (>3 tubular anechoic
structures each measuring ≥1 mm in width,
budding from the MPD)
Hyperechoic MPD wall (echogenic, distinct
structure >50% of entire MPD in the body
and tail)
15. Chronic Pancreatitis-
Hyperechoic duct strand
Foci of pancreatic calcificationHyperechoic foci of pancreatic
parenchyma
Lobularity- Pancreatic
parenchyma is lobulated by
linear hyperechos
Duct irregularity
17. Other Uses
CBD Calculi
EUS has progressed from a
diagnostic procedure to an
important therapeutic tool.
Used in obtaining pancreatic
biopsies or FNA.
Used in coeliac plexus block to
curb the abdominal pain
caused due to chronic
pancreatitis or pancreatic
malignancy.
18. Disadvantages of EUS:
Requires sedation
Can cause bleeding
Limitations to inaccessible areas
Perforation (less than 1 in 1000s)
Infection (can be prevented by giving pre-procedure antibiotic)
20. Introduction
First described by Kappis et al. in 1919
CPN is a chemical splanchnicectomy of the
celiac plexus.
Its goal is to ablate the efferent nerve fibres
which transmit pain from the intra-
abdominal viscera.
Celiac plexus is situated below the
diaphragm (ante-crural), surrounding the
basis of the celiac trunk.
It is composed of a dense network of
ganglia and interconnecting fibres.
21. Procedure
Linear EUS is introduced into the stomach
to reach the lesser curve in the sub-cardiac
area.
At this site, it is easy to identify the aorta
under the diaphragm which appears as an
anechoic tube structure in a longitudinal
plane.
The origin of the celiac axis is seen beside
this.
Color Doppler can confirm the vascular
landmarks.
Celiac plexus is not identified as a discrete
structure but is located based on its
position relative to the celiac trunk.
Color Doppler visualization of the celiac
trunk
22. EUS 20 CPN needle is a special needle
designed for this procedure.
Closed penetrating tip with some lateral
holes- allow a radial diffusion of neurolytic
agents to both sides of the origin of the
celiac axis with a single injection.
When the needle tip is in place, an
aspiration test is performed to rule out
vessel penetration before injection.
Then, 3-6 mL of a local anaesthetic, usually
bupivacaine 0.25-0.75%, is injected first
followed by 15-20 mL of a neurolytic agent
(98%) dehydrate alcohol. EUS 20 CPN Needle
23. Advantages
1. Safer than posterior
percutaneous techniques
because EUS allows direct
access to the celiac plexus
without risk to the vital spinal
nerves, the diaphragm or the
spinal arteries.
2. Useful to curb the pain due to
chronic pancreatitis.
3. In palliation of pts with pain
caused by unresectable
pancreatic cancer.
1. Bleeding
2. Diarrhea
3. Orthostatic hypotension
4. Peripancreatic abscess
5. Reversible paraparesis
Disadvantages
25. Most sensitive diagnostic test for early CP as subtle functional changes occur
at an early stage of fibrosis.
EPFT collects pancreatic fluid after a 0.2mcg/kg of synthetic secretin (human
or porcine) is injected intravenously.
Indication:-
1. evaluation of possible early exocrine dysfunction in patients with
abdominal pain
2. the determination of the etiology of steatorrhea
Most common cause of pancreatic exocrine insufficiency in adults is chronic
pacreatitis.
Gradual and irreversible replacement of normal pancreatic tissue by
inflammation and fibrosis causes concomitant decrease in exocrine function
of the duct and acinar cells.
26. Procedure
Gastric fluid is aspirated as completely as possible through the scope
and discarded.
At time “0” a baseline collection of 3-5 cc of duodenal fluid is
collected in a trap (bottle A). Also at time “0”, the full IV dose of
synthetic secretin (0.2 mcgs/kg, slow push) is administered.
Intermittent 3-5 cc fluid aspirates are obtained every 15 minutes for
an hour (Bottles B at 15 minutes, C at 30 minutes, D at 45 minutes,
and E at 60 minutes).
Fluid should be kept on ice and analyzed within 6 hours, or may be
frozen (subzero freeze) and analyzed later for bicarbonate
concentration.
27. Interpretation
The highest bicarbonate concentration from the 5 samples is
considered the peak bicarbonate.
A peak bicarbonate <= 80 mEq/L is considered abnormal and
suggestive of exocrine insufficiency.
Duodenal fluid before, during, and after Secretin Stimulation
29. Cannulation
Selective cannulation of the bile and pancreatic
ducts is a prerequisite for interventional
procedures.
Can be performed by
1. Standard cannulation catheters,
2. Sphincterotomes, also called papillotomes
The main difference between these 2 is that a
sphincterotome has an electrosurgical cutting
wire at the distal end of the catheter.
Hence, it has the advantage of enabling
immediate sphincterotomy after cannulation.
It also helps in selective cannulation of the bile
duct by upward bowing in a caudocranial axis.
Standard Cannulation Catheter
Sphinterotome
30. If free cannulation with a cannulating catheter
fails, guidewire cannulation can be attempted.
Hydrophilic guidewires with a special slippery
coating are ideal for cannulation because they
minimize trauma to the papilla and more
effectively seek out the path to the desired duct.
The guidewire is extended several millimeters from
the tip of the cannula or sphincterotome, and the
papillary orifice is cautiously probed with the wire
until it slips into the duct.
Cannulating catheter loaded with
guidewire to assist cannulation
31. Rendezvous Procedure
Biliary or pancreatic duct cannulation can
be aided by a combined percutaneous
and endoscopic approach k/a
Rendezvous Procedure. (Mallery et al,
2004)
The bile or pancreatic duct is punctured
transduodenally or transgastrically with a
standard FNA needle loaded with a
guidewire under EUS guidance.
The wire is advanced anterograde across
the stricture into the duodenum.
The stent is placed over the wire in the
standard retrograde fashion.
32. A further variation of the rendezvous approach can be used to
achieve cannulation of the pancreatic duct.
The minor papilla is used to pass a wire from the duct of Santorini
into the duct of Wirsung and then across the major papilla.
When cannulation of the major papilla is achieved, the wire is
rerouted from the minor papilla to the main pancreatic duct.
Advantage: Reduces the chances of Post- endoscopic pancreatitis
(PEP) compared with conventional biliary cannulation.
Reduced incidence from 3.6% to 2.2%
The American Journal of Gastroenterology 108, 552-559 (April 2013)
33. Precutting (papillary roof incision)
It is a useful technique to achieve selective
bile duct cannulation when free or wire-
guided approaches fail.
The objective of precutting is to incise the
roof of the papilla to expose the
underlying opening of the bile and
pancreatic ducts for selective cannulation.
The endoscopist initiates the papillotomy
by placing the needle-knife at upper
portion of the papillary orifice, near the 12
o’clock position, and initiates the cut
upwards from the orifice.
Precut Papillotomy
34. For the cannulation of pancreatic duct,
Transpancreatic precut sphincterotomy
is performed.
Sphincterotome is oriented in the
direction of the CBD a approximately the
11 o’clock position, and is then inserted
superficially into the PD.
Disadvantages of Precut:
1. significant risk factor for
postsphincterotomy pancreatitis
2. there have been isolated reports of
perforation.
Transpancreatic precut sphincterotomy
36. Juxtapapillary Duodenal Diverticula
Frequently found in elderly patients
Alter the position and anatomic
boundaries of the papilla and displace
the course of the bile and pancreatic
ducts, making cannulation more
difficult. Juxtapapillary Duodenal Diverticulum
37. Correction:
1. Aspirating air from the diverticulum
may help “evert” the diverticulum,
bringing the papilla into a more
favorable position for cannulation.
2. Altering patient position and applying
abdominal pressure also may be
helpful.
3. Failing these, a small depot of normal
saline can be injected into the
submucosal plane of the mucosa
adjacent to the papilla. The injection
should be made on the diverticular side
of the papilla in an attempt to “tilt” the
papilla toward the endoscopist.
Cannulation done after injecting saline
38. Billroth II gastrectomy cannulation
Accessing the papilla is the first
obstacle.
The afferent loop can be difficult to
intubate, and the papilla can be
difficult to reach when the afferent
loop is long.
Cannulation of the Billroth II papilla is
the second obstacle.
Because the endoscope approaches
the papilla from below rather than
above, the papillary anatomy in a
Billroth II patient is reversed.
39. The bile duct is cannulated by
orienting the catheter
downward at the 5 to 6
o'clock position, rather than
the standard 11 to 12 o'clock
position.
It is helpful to use a new
straight catheter or mold a
downward bow into the
catheter to achieve this.
41. Introduction:
Aims at opening the terminal part of the
common bile duct or pancreatic duct by
cutting the papilla and sphincter muscles.
Although not always mandatory for
interventional procedures, it greatly
facilitates ductal access and manipulation.
The standard sphincterotome (Erlangen
“pull-type” model) consists of a catheter
containing a cautery wire, which is exposed
20 to 25 mm near the tip of the instrument.
The leading tip distal to the wire (“nose”) is 5
to 10 mm.
Erlangen sphincterotome
42. Procedure:
After deep bile duct cannulation, the
sphincterotome is retracted slowly until one
fourth to one half of the wire length is exposed
outside the papilla.
The sphincterotome is slightly bowed so that
the wire is in contact with the roof, but not
excessively to avoid a “zipper” incision.
The incision is made by gently lifting the
sphincterotome against the papillary roof using
the elevator and up-down controls while
applying short bursts of current.
43. The length of a bile duct sphincterotomy depends on the indication.
A small incision (≤1 cm) is adequate for stent insertion, whereas stone
extraction usually requires a larger incision depending on the size of
the stone to be extracted.
The length of a pancreatic duct sphincterotomy should not exceed
1cm because of the perpendicular insertion at the ampulla.
The adequacy of a sphincterotomy can be gauged by the ability to
move the bowed sphincterotome across the opening.
44. Special Cases:
In the presence of a juxtapapillary diverticulum, the incision should
be performed in millimeter increments, paying close attention to the
boundaries of the incision and the course of the intraduodenal
segment of the bile duct.
In a Billroth II patient, the standard Erlangen-type sphincterotome is
not suited for sphincterotomy because of the reversed anatomy.
The Soehendra Billroth II sphincterotome is designed to produce an
upside-down bow in the cutting wire so as to orientate the wire
correctly within the bile duct.
45. 1. PS haemorrhage- more while using
pure cutting current
2. PS pancreatitis- more while using
blended current than in pure cutting
The best practice to avoid these complications is
by performing
the first third of the sphincterotomy with the
generator in the cut setting,
the middle third with blended current,
and the final third with coagulation current.
Complications
Duty cycle- refers to the % of total time that electrical
current is actually delivered. This is dependent on the
frequency and duration of any pauses that are
programmed into the cycle
Pure Cut- 100% duty cycle
Coag current- 6% duty cycle
Blended current- preset duty cycles ranging from 12-80%
46. Rationale: The risk of causing pancreatitis is highest during the initial
portion of the Sphincterotomy.
The risk of causing bleeding is highest near the apex of the
sphincterotomy (because of the proximity of the pancreatic orifice and
blood vessels, respectively).
3. Retroperitoneal perforation- that results from an uncontrolled
“zipper-cut”.
can be avoided by ensuring that enough wire is withdrawn from the papilla.
48. Stone Extraction
85% of pancreatic stones & approx. 90% of
bile duct stones can be removed effectively
after endoscopic sphincterotomy combined
with the Dormia basket or balloon catheter.
The choice of basket or balloon is largely
dictated by stone size.
The Dormia basket is sturdier and provides
better traction for removal of a larger stone.
The balloon catheter occludes the lumen and
is ideal for removing small stones or sludge.
Dormia basket with large
stone extraction
Balloon catheter with
small stone extraction
49. Points to remember during stone extaction
Technical points to increase the success rate of stone extraction.
1. Sphincterotomy should be generous enough.
(The adequacy of the incision can be assessed by passing an inflated balloon
catheter through the sphincterotomy opening.)
2. If multiple medium or large stones are present, it is important to
remove stones individually, beginning with the lowermost stone, to
avoid stone impaction.
3. If pancreatic duct stones tend to be firmly impacted or form
proximal to a stricture, a preliminary fragmentation using lithotripsy
techniques would be required.
50. Standard stone extraction techniques may fail when a stone is large,
impacted, multiple, or proximal to a stricture.
A variety of modalities are currently available to fragment these
“difficult” stones before extraction, includes
mechanical lithotripsy,
intraductal shock wave lithotripsy,
extracorporeal shock wave lithotripsy, and
dissolution therapy.
51. Mechanical Lithotripsy
A mechanical lithotripter consists of a wire basket, a metal sheath, and a handle,
which provides mechanical retraction of the basket into the metal sheath,
directing a crushing force to the stone.
Through the scope lithotriptor
Used while the endoscope remains in the patient.
Out of scope lithotriptor
Attached to retrieval basket after the endoscope has
been removed.
52. Intraductal Shock wave Lithotripsy
Intraductal lithotripsy is performed using flexible probes
that can be introduced into the bile or pancreatic duct.
The shock waves are generated using electrohydraulic
or laser technology and are applied directly to the stone
surface.
(Binmoeller et al, 1993; Cotton et al, 1990; Leung & Chung, 1989;
Siegel et al, 1990)
Because shock waves can cause injury to the duct wall,
intraductal lithotripsy generally is performed under
endoscopic guidance using a “babyscope” that is
inserted into the duct via the duodenoscope, or
“motherscope”.
The lithotripsy probe is inserted through the operating
channel of the babyscope, and shock waves are fired
under visual guidance until adequate stone
fragmentation is achieved.
Short Access Minimal Mother
Baby (SAMBA) scope
53. Extracorporeal Shock Wave Lithotripsy
Extracorporeal shock wave lithotripsy has been shown to be an
effective and safe method to fragment bile and pancreatic duct
stones that defy endoscopic extraction.
But in a prospective randomized study, extracorporeal shock wave
lithotripsy was found to be less effective than intraductal shock wave
lithotripsy because-
50% of patients require adjunctive treatments to achieve complete
ductal clearance of stone fragments. (Bland et al, 1989)
50% of patients require subsequent stenting for associated strictures.
(Delhaye et al, 1992; Smits et al, 1996b)
55. Introduction
Pancreatic duct strictures is one of the most
common complications of chronic
pancreatitis, sclerosing cholangitis or post-
operative injury (iatrogenic).
Stricture dilation can be performed using
push-type dilation catheters (bougies) or
high-pressure hydrostatic balloons.
Balloon dilation is usually used in
conjunction with stent placement to
maintain the dilation effect.(Davids et al, 1992)
High-pressure hydrostatic balloon
56. Procedure
The balloons are available in varying
lengths (2, 3, and 4 cm) and diameters (4,
6, and 8 mm).
When inflated, the balloon applies radial
dilating force.
The balloon is inflated with diluted contrast
material to the maximum atmospheric
pressure allowable and kept inflated until
the stricture “waist” disappears (generally
30-60 seconds of inflation).
Dilation is painful, and this may limit the
duration of inflation.
Sequential brief dilations may be better
tolerated.
Stenting done in
pancreatic duct stricture
57. Soehendra Rotational Device
Used for tight strictures that do not permit
passage of a bougie or balloon
Has a threaded tip at its end with a central
lumen for coaxial guidewire insertion.
After placement of a guidewire across the
stricture, the retriever device is coaxially
inserted until it engages the stricture.
The rotational device is rotated clockwise at
the handle by the assistant, while the
endoscopist advances the device across the
stricture.
59. Introduction
Endoscopic transpapillary stent placement is a well-standardized
technique today and can be carried out with an overall success rate of
greater than 90%.
Stenting has become the treatment of choice for the palliative
decompression of malignant distal biliary obstruction
It is an accepted alternative to surgery for the treatment of benign
distal biliary and pancreatic strictures.
Stenting also has been found to be an effective treatment for bile and
pancreatic duct leaks.
60. Types of Stents
1. Plastic, may be-
a. straight, with flaps for
anchorage;
b. single pigtail; or
c. double pigtail
2. Self expandable metal (SEMS),
may be-
a. uncovered; or
b. covered
Plastic stents- Straight, single pigtail, double pigtail
Metal stents- uncovered and covered
61. Plastic Stents Metal Stents
Advantages 1. Cheaper 1. Longer patency (> for
covered)
2. Significantly less stent
occlusion by 4 months
3. Reduced risk of recurrent
biliary obstruction
4. Least chances of stent
migration with
uncovered SEMS
Disadvantages 1. Shorter patency < 3
months
2. High chances of stent
occlusion
3. Overall high incidence of
stent migration
4. Post stenting pancreatitis
1. Costly
2. Higher incidence of stent
migration with covered
SEMS
3. Post stenting pancreatitis
62. Procedure
A small sphincterotomy is performed to facilitate insertion of further
instruments.
The stricture is negotiated with a guidewire.
Special hydrophilic wires allow easier and less traumatic passage
through strictures.
When stricture is passed with a wire, a dilating catheter is coaxially
inserted to dilate the stricture.
A stent (plastic or expandable metallic) is inserted using the Seldinger
technique.
63. Postoperative biliary strictures and
pancreatic strictures secondary to chronic
pancreatitis may require 1 year of stenting.
(Binmoeller et al, 1995; Smits et al, 1996)
The placement of multiple stents by adding
a stent at 3-month intervals may optimize
the dilation effect.
Multiple stents
placement
65. Introduction
Used in Necrotising pancreatitis
Limited to Walled Off N.P
(WOPN)
Performed via transgastric or
transduodenal approach
When to operate:-
• Wait at least 3 to 4 weeks.
• Waiting for encapsulation or “walling off” is
critical to the success of primary endoscopic
therapy, and often directly correlates with the
degree to which the collection is encapsulated.
66. Procedure
Areas of pancreatic necrosis identified.
A transluminal puncture made.
Guidewire placed into the cavity to facilitate advancement of a large (up
to 20 mm) hydrostatic balloon for dilatation of the gastric wall.
Once the gastrostomy is established, direct endoscopic debridement
done.
At the end of the debridement, stents are placed into the cavity.
A 7-French pigtail nasocystic tube alongside the stents is placed for
postoperative intracavitary lavage.
67. Advantages
1. Low procedure related morbidity
and mortality
2. Less risk of post procedure
pancreatic fistula as internal
drainage is established.
1. Necrosis has to be walled-off and
endoscopically accessible.
(inaccessible -> Rt. & Lt. retroperitoneal
extensions mainly in psoas muscle)
2. Requires repeated procedures
for resolution
3. High risk of local bleeding
complications
Early (<24hrs)- due to avulsed
peripancreatic vessels
Late (>24hrs)- due to rupture
pseudoaneurysm
Disadvantages
69. Introduction
Management of cystic lesions of the pancreas requires careful, directed diagnostic
evaluation utilizing a multidisciplinary approach.
It is important to confirm that the cystic lesion is a pseudocyst and not a cystic neoplasm
of the pancreas.
Pancreatic pseudocyst formation requires
disruption of the pancreatic ductal system
inflammatory reaction of surrounding tissues
That results in formation of a fibrous capsule or wall that lacks an epithelial lining.
70. Pseudocyst results from fluid collection persisting for more than 4 WEEKS after the
onset of an episode of Acute Pancreatitis (in 5% to 15% of patients) or Chronic
Pancreatitis (>25%).
-Jacobson
Causes can be-
Isolated injury due to blunt abdominal trauma
Transection of the main pancreatic duct during pancreatic resection
Acute pancreatitis due to alcohol or gallstones
When to operate:
In symptomatic patients
Those with pseudocysts >6cm
With wall thickness >6mm
That have failed to resolve over a set time interval (6 wks).
(Canine models of pseudocyst formation, 1950; Edward Bradley, 1970)
71. Role of EUS
Provides invaluable information to rule out cystic neoplasms.
Including
cyst content,
wall nodularity,
Vascularity,
Septations.
EUS also allows for fine needle aspiration of the cyst cytology.
Mucin content, viscosity, amylase and carcinoembryonic antigen
(CEA) can help differentiate pseudocysts from cystic neoplasms.
72. Nealon's Classification: Endoscopic Retrograde
Cholangiopancreatography
Nealon and Walser have demonstrated
the importance of ductal anatomy in the
management of pseudocysts.
Patients with a normal pancreatic duct
without communication to a pseudocyst
and acute pancreatitis had shorter length
of drainage and hospital stay than
patients with complete cutoff of the duct
(Nealon Type V).
All patients with chronic pancreatitis
(Nealon Type VI, VII) fail to respond to
percutaneous drainage and ultimately
require surgical intervention.
73. The choice of treatment (open, percutaneous, or endoscopic) depends on
multiple factors including
size,
number,
location of the cyst,
the presumed absence of infection or residual necrotic tissue,
the presence or absence of a cyst-duct communication,
the availability of specialists in endoscopy.
Different endoscopic techniques that are used for pseudocyst drainage
are—
1. Transpapillary Drainage
2. Transmural Drainage
75. Introduction:
Endoscopic transpapillary drainage is
effective for pseudocyst that
communicate with the pancreatic
duct (Nealon type II).
In it, an attempt is made to drain the
pseudocyst content into duodenum.
76. Procedure
A side-viewing duodenoscope is passed up to the level of the ampulla
of Vater.
Biliary access is obtained by directing the sphincterotome superiorly
and anteriorly in the ampulla toward the 11 o'clock direction.
Decompression of the pancreatic duct done.
A stent with appropriate length and a caliber of 7 French is then
passed over the guide wire into the pseudocyst.
77. The stent remains in the
pancreatic duct until the
pseudocyst resolves or
significantly decreases in
size as demonstrated by
CT.
Stent removal, re-
evaluation and
replacement usually
occur in 6 to 8 weeks.
Pancreatic Pseudocyst with
insertion of guide wire
PD Balloon Dilatation
PD Stent
79. Introduction:
In this method, a direct cyst-gastrostomy or
duodenostomy is performed.
For non communicating pseudocyst.
On examination of the gastric or duodenal
lumen, those patients with pseudocyst
indentation of the enteric lumen are
candidates for transmural drainage.
endoscopic view of bulging pseudocyst
in stomach
80. Procedure:
A needle knife is used to open the indented area of the enteric
lumen.
A small area of 3 to 5 mm of mucosa is cauterized and the needle
knife is used to puncture the center of this area.
Extrusion of cyst fluid is encountered when the cyst is entered and a
guide wire is then passed though the center of the needle knife into
the cavity.
A sphincterotome can be passed over the wire to enlarge the cyst-
enterostomy.
A radial expansion balloon can be used to dilate the cystenterostomy
in cases where there is bleeding from the mucosa.
An opening of a minimum of 1 cm is preferable.
81. The pseudocyst is drained
with one to two 10 French
stents, side by side.
Double stenting is more
effective than a single stent
because single stents can be
encased by gastric mucosa
and induce infection when
their lumen becomes
occluded.
Initial use of cautery to enter
into the pseudocyst
Guide wire placed through cyst gastrostomy Gastric view of stents
83. Introduction
Adenomas of the major duodenal
papilla, also k/a ampullary adenomas,
can occur sporadically or in the context
of genetic syndromes such as familial
adenomatous polyposis (FAP).
These lesions have the potential to
undergo malignant transformation to
ampullary carcinoma.
Ampullary adenomas
84. Surgical management often allows
complete removal but carries
morbidity, including anastomotic
dehiscence (9%) and fistulae
(14%).
Endoscopic approaches for the
evaluation and treatment of
ampullary adenomas now
represent a viable alternative to
surgical therapy. Endoscopic view of ampullary adenoma
85. Role of EUS
EUS and intraductal US (IDUS) have emerged as useful techniques to
assess the depth of involvement in patients with ampullary neoplasms.
These modalities allow
assessment and extent of intraductal extension
extension beyond the muscularis propria
evaluation of periampullary lymph nodes in patients suspected of
carcinoma.
Lesions less than 1 cm in diameter or those that do not have suspicious
signs of malignancy (ulceration, induration, bleeding) do not require
ultrasonographic evaluation before endoscopic removal.
86. Procedure
In this technique snaring of the papilla with
the duodenal wall is done.
Special diathermic snare are available.
Before endoscopic papillectomy is
performed, it is important to inject saline in
the sub mucosa.
Failure of a lesion to manifest a ‘‘lift sign’’ is
associated with malignancy and is
considered a contraindication to attempts at
complete endoscopic resection.
Diathermy snare
87. If the lesion can be completely ensnared, en
bloc resection with electrocautery can be
performed.
Piecemeal resection (with electrocautery) is
often performed for lesions larger than 2 cm
or in cases where an attempt at en bloc
resection has left visible neoplastic tissue in
place.
Surgical resection is indicated if the specimen
shows malignancy, or complete excision
cannot be achieved endoscopically.
Periodic endoscopic surveillance is mandatory
to evaluate for adenoma recurrence.
88. Endoscopic Surveillance
Initial surveillance examination- 1 to 6 months after the index
procedure.
Followed by repeat examinations with a duodenoscope every 3
months thereafter for a period of at least 2 years.
89. References
• Grant’s Atlas of Anatomy, 13th Ed.
• Sobotta’s Atlas of Anatomy, 15th Ed.
• Skandalakis Surgical Anatomy
• Love and Bailey Textbook of Surgery, 26th Ed.
• Fischer’s Master of Surgery, 6th Ed.
• Blumgart: Surgery of the Liver, Biliary Tract and Pancreas, 4th Ed.
• Schwartz Principles of Surgery, 10th Ed.
• Internet
Editor's Notes
Anlage- rudimentary basis of certain organ
Due to unopposed parasympathetic vagal response, enhancing intestinal peristaltic activity Usually transient
The duodenal bulb is the portion of the duodenum which is closest to the stomach. It normally has a length of about 5 centimeters. The duodenal bulb begins at the pylorus and ends at the neck of the gallbladder.[1] It is located posterior to the liver and the gallbladder, and superior to the pancreatic head
direct function testing
human fecal elastase-1 test