Biliary and Pancreatic Endoscopy Stones, Strictures, and IPMN

Transcription

1 WE MAKE LIVES BETTER UTHSC SAN ANTONIO Memorial Hermann Gastroentrology & Hepatology Symposium February 10, 2018 Biliary and Pancreatic Endoscopy Stones, Strictures, and IPMN Sandeep N. Patel, DO Director, Pancreas Center University of Texas Health Science Center, San Antonio, TX, USA

2 Role of Intraductal Endoscopy Overview Biliary Stones Indeterminate biliary strictures Pancreas Stones IPMN

3 EndoscopicRetrogradeCholangioPancreatography Diagnosis Therapy: Sphincterotomy Stenting Dilation Sampling Fluoroscopic imaging

4 Intraductal Endoscopy Evolution mother-baby system Single-Operator technique 1970 s 2007

5 Intraductal Endoscopy Evolution 2015 SpyGlass DS

6 WE MAKE LIVES BETTER UTHSC SAN ANTONIO Indeterminate biliary strictures and filling defects..

7 Sampling of CBD Strictures ERCP Yield: brush ~ 30% biopsy ~ 30% Serial brushing Dilation and brush Novel brushes Smash technique 30-50%

8 Sampling of CBD Strictures Directed biopsies using SpyGlass 56 yo female with recurrent cholangitis Undergoes 3 ERCP s at OSH Filing defect CHD/stricture Brushings, biopsies negative for CA Prematurely occludes stents Referred for management What should we do?

9 WE MAKE LIVES BETTER UTHSC SAN ANTONIO Case #1

10 Sampling of CBD Strictures Directed biopsies using Digital SpyGlass

11 WE MAKE LIVES BETTER UTHSC SAN ANTONIO Case #2

12 Sampling of CBD Strictures Directed biopsies using Digital SpyGlass

13 WE MAKE LIVES BETTER Case UTHSC SAN ANTONIO #3

14 Registry Data tissue acquisition-spyglass Analysis of the data set of indeterminate strictures - intrinsic (intralumenal) Sensitivity 78% (21/27) Specificity 64% (7/11) Positive Predictive Value 95% (21/22) Negative Predictive Value 58% (7/12) Analysis of total data set of indeterminate strictures - extrinsic and intrinsic (intralumenal) Sensitivity 59% (23/39) Specificity 75% (3/4) Positive Predictive Value 100% (23/23) Negative Predictive Value 20% (3/15) Results from Biopsy of Indeterminate Biliary Strictures Does Direct Visualization Help? A Multicenter Experience Presented by K.F. Binmoeller, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA

15 . Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a singlecenter, prospective study. Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Darisetty S, Sekaran A, Rao GV. The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis. Gastrointest Endosc Sep;74(3):511-9

16 Can we do even better? 58 yo male newly diagnosed PSC Pruritic CA-19 high No dominant strictures Does he have cancer? Where?

17 Sequela: Abdomnal pain Jaundice Cholangitis Acute Pancreatitis

18 ERCP Stone Extraction Techniques Success Sphincterotomy/extraction balloon/basket 80% Mechanical lithotripter 90% Binmoeller KF, Soehendra N, et al., Endoscopy 1993

19 ERCP Stone Extraction limitations Altered anatomy Large BD stones (>2cm) Difficult stones Intrahepatic stones Stone(s) above a stricture

20 ERCP Stone Extraction success rate Techniques Success Sphincterotomy/extraction balloon/basket 80% Mechanical lithotripter 90% 1 EHL/Laser ~100% 2 1. Binmoeller KF, Soehendra N, et al., Endoscopy Maydeo A, Kwek BE, et al. GIE 2011

21 Electrohydrolylic Lithotripsy (EHL) Spark between electrodes at fiber tip. Sparks induces a spherical shock wave. Shock wave oscillates to fragment the stone. Done under direct visualization ** Very high energy **

22 Electrohydraulic Lithotripsy for Common Bile Duct Stones Author n Clearance Complications Liguory % Bonnel % hemobilia = 21 Binmoeller % cholangitis = 22 Siegal % pancreatitis = 3 Yoshimoto % perforation = 3 Adamek % hemothorax = 1 Arya % bile leak = 1 Piraka % Others * % n = % 51/492 (10%) * Summary of studies (23) with < 15 pts. Patel S, Rosenkranz L. ERCP for stone burden in the bile and pancreatic ducts. Clin of North A merica 2012.

23 Light Amplification by Stimulated Emission of Radiation

24 Various Lasers Several are available Differ in: Yttrium Aluminum wavelength pulse length pulse energy Erbium Neodymium Holmium

25 Why Holmium?? Wavelength (2120 nm) = water Low pulse length low energy shock wave **** Equally effective, less traumatic ***** Vassar et al. J Endourol 1999

26 Laser Lithotripsy Pulsed laser causes instantaneous fluid evaporation This induces formation of cavitation bubble Bubble collapse leads to shock wave photo-mechanical effect Bigger the bubble --> stronger the mechanical effect

27 Holmium:YAG laser safety data on bile duct epithelium in the porcine model 6 female 50 kg domestic pigs underwent necropsy and the bile ducts (BD) were explanted. Statistically Significant Differences in Time to Perforation* Median Time to Perforation 8 W vs 15 W s W vs 15 W 10 W vs 15 W 12 W vs 15 W * Pairwise multiple comparison by Dunn's Method (P<0.05) W Sandeep Patel, Dustin Kiker, Joanna Lindsteadt, Bryan Hanysak. GIE 2009

28 Refractory Stone Extraction laser lithotripsy 10W with 365 probe

29 Holmium-YAG Laser Lithotripsy in the Treatment of Pancreaticobiliary Calculi Utilizing (SpyGlass): A Multi-Center Trial. 74 pts (27 male, 47 female; mean age of 60.2 years ranging from 20-96) underwent holmium:yag lithotripsy at four participating centers. Total number of patients 74 Extrahepatic stones 57/74 (77.2%) Intrahepatic stones 8/74 (10.3%) Cystic duct stones 4/74 (5.4%) Pancreatic stones 5/74 (6.8%) Prior failed ERCP attempts µ=1.4 (1-6) Sessions needed for ductal clearance µ=1.2 Patients requiring one session 23/31 (74.2%) Attained ductal clearance a) biliary b) pancreatic Procedural time 67/ 69 (97.3%) 7/10 (70%) µ=69 min (5-105 min) Procedural-related complications 3/74 (4.1%) S. Patel, L. Rosenkranz, B. Hooks, P. Tarnasky, D. Fishman, I. Raijman,, B. Sauer, M. Kahaleh. GIE 2014

30 Results of Laser Lithotripsy: FREDDY and Holmium:YAG. Author n clearance complications FREDDY Cho % 23% Lui % 7% Kim % 17% Holmium:YAG Lee % 10% Maydeo % 14% Patel % 4% Patel S, Rosenkranz L. ERCP for stone burden in the bile and pancreatic ducts. Clin of North A merica 2012.

31 Refractory Stone Extraction laser lithotripsy 12W with 550 probe

32 WE MAKE LIVES BETTER UTHSC SAN ANTONIO Approach to pancreatic diseases

33 WE MAKE LIVES BETTER UTHSC SAN ANTONIO pancreatoscopy Treatment of Pancreatic Stones

34 WE MAKE LIVES BETTER UTHSC SAN ANTONIO Conventional ERCP therapies ESWL Management of pancreatic duct stones pancreatoscopy lithotripsy EHL Laser

35 Holmium:YAG for PD stones

36 Per Oral Pancreatoscopy with Intraductal Holmium Laser Lithotripsy for Treatment of Main Pancreatic Duct Calculi: A Multi-Center U.S. Experience N=28 (male 12; female 16; = 57yo) Technical Success: 97% Complete Stone Clearance: 86% Median # sessions 1 (range 1-6) Clinical improvement 97% Complications 4% Shah R, Attwell A, Raijman I, Kahaleh M, Fukami N, Patel, S [abstract]. Presented DDW 2012

37 WE MAKE LIVES BETTER UTHSC SAN ANTONIO pancreatoscopy Evaluation of intraductal papillary mucinous neoplasm

38 Intraductal Papillary Mucinous Neoplasm (IPMN) background First described in 1982 Proliferation of mucus-producing ductal epithelial cells. Precancerous lesion Rate of progression to carcinoma slow features: Patulous ampullary orifice Dilated pancreatic duct Mucus secretion

39 Intraductal Papillary Mucinous Neoplasm (IPMN) background Side branch IPMN Combined disease Main duct disease

40 Management of IPMN Sendai Consensus Guidelines Main Duct IPMN PD > 10mm Intramural nodules Thickened walls Suspicious or positive cytology Symptomatic Surgery Sensitivity = 100% Specificity = 25-30% Tanaka M et al. Pancreatology 2012;12: 198

41 Evaluation of Intraductal Papillary Mucinous Neoplasm (IPMN) Current limitations: Tissue sampling: Mucinous vs non-mucinous malignant vs non-malignant Cytology: yield = 40-50% EUS-FNA Fluid analysis CEA K-ras LOH MUC 2,4,5AC GNAS mirna Grutzmann R et al. Oncologist 2010;15:1294

42 Evaluation of Intraductal Papillary Mucinous Neoplasm (IPMN) Current limitations: Pre-operative planning: Whipple Distal pancreatectomy Total pancreatectomy What is the extent of disease? Is there multi-centric disease (~20%)? Hidetoshi et al. Cancer 107:2567

43 Intraductal Papillary Mucinous Neoplasm (IPMN) Diagnosis? Treatment?

44 How well does pancreatoscopy dx pancreatic cancers? 115 patients undergoing pancreatoscopy: 35 pts with adenocarcinoma 60 pts with IPMN Fish-egg Elevated lesions Friable mucosa Papillary projections Tumor vessels 63% 95% K. Yamao, et al. Efficacy of peroral pancreatoscopy in the diagnosis of pancreatic diseases, Gastrointest Endosc 57 (2003)

45 Diagnostic Yield of Pancreatoscopy for IPMN Author n Sens Specificity Pancreatoscopy Hara 60 66% 87% Pancreatoscopy + biopsy Tetsuya et al % 100% Yamao et al % 100% Patel et al % 100%

46 Pancreatoscopy with narrow-band imaging White light ( nm) vs Blue (415 nm) and Green (540 nm) light Enhancement of mucosal vascular pattern 1. Yelamali,N. Reddy, et al. Surg Endosc (2012) 26: Muira, T et al. Dig Endosc 2010;22: Itoi T et al. Gastrointest Endosc 2007;66:793 Vascular patterns and protrusions are detected more clearly than with white light

47 Intraductal Endoscopy for Biliary Disease conclusion Stones and strictures Almost all biliary stones can be managed endoscopically. Now improved biliary imaging available to all, with complimentary modalities coming.

48 Intraductal Endoscopy for Pancreatic Disease conclusion IPMN and Pancreatic duct stones Pancreatoscopy improves diagnostic yield in IPMN Pancreatoscopy may be a useful modality in guiding surgical resection for MD-IPMN Pancreatoscopy with EHL/Laser is an effective modality for removal of pancreatic duct stones.

49 WE MAKE LIVES BETTER UTHSC SAN ANTONIO Thank you