Best of UEG week 2017 (Pancreas-biliary)

Transcription

1 Best of UEG week 2017 (Pancreas-biliary) Marianna Arvanitakis Erasme University Hospital, ULB, Brussels, Belgium 10 th Nottingham Endoscopy Masterclass

2 SPEAKER DECLARATIONS This presenter has the following declarations of relationship with industry NONE [28/10/17]

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4 OP103: COVERED VS UNCOVERED SEMS FOR PALLIATION IN MALIGNANT CBD STRICTURES: A RCT ESGE guidelines 2012 Clin Gastrol Hepatol 2013 Latest meta-analysis of 9 RCTs (1061 patients) No difference in stent patency, AP, cholecystitis, cholangitis, perforation, LoS Covered SEMS: More stent migration (OR 7.1) More tumor overgrowth (OR 1.9) Less tumor ingrowth (OR 0.2) Mangiavillano et al, UEG journal 5S, A444

5 OP103: COVERED VS UNCOVERED SEMS FOR PALLIATION IN MALIGNANT CBD STRICTURES: A RCT RCT: Primary end-point Stent patency Secondary end-point AE FC SEMS NitiS Biliary N=78 Uncovered SEMS NitiS Biliary N=78 148/156 analysed Technical success 98.7% 100% NS Decrease in bili -70% -68% NS Normalisation in bili 28.2% 28.9% NS AE 25.4% 13.1% 0.09 Migration 7% 0% Stent patency 9.5 mo 18 mo Mangiavillano et al, UEG journal 5S, A445

6 OP107: DIGITAL SOC FOR TREATMENT OF DIFFICULT STONES International, multicenter, retrospective study 407 patients with difficult bile stones (2/15-2/16) D-SOC with laser lithotripsy or electro-hydraulic lithotripsy Difficult stones: large (15mm), multiple, impacted, cystic/ih duct, Mirizzi syndrome, biliary stricture Failed ERCP before treatment: 85.8% End points: Technical success Safety Brewer-Guttierez et al, UEG journal 5S, A45 6

7 OP107: DIGITAL SOC FOR TREATMENT OF DIFFICULT STONES Total (n=407) EHL (n=306) LL (n=101) P Technical success 396 (97.3%) 296 (96.7%) 100 (99%) NS Number of sessions (med) Need for ESWL or surgery Duration of procedure (min) 1(1-4) 1 (1-4) 1 (1-4) NS NS <0.001 Brewer-Guttierez et al, UEG journal 5S, A45 7

8 OP105: SHORT TYPE DBE FOR ERCP: A LARGE CASE SERIES Usefulness of new short DBE for ERCP on postoperative patients Retrospective study with 222 post-operative patients (280 procedures) End points: Success rate and time for reaching the blind end Diagnostic success rate Therapeutic success rate Overall success rate Mean time to complete DB-ERCP Adverse effects Shimatani et al, UEG journal 5S, A44 8

9 OP105: SHORT TYPE DBE FOR ERCP: A LARGE CASE SERIES RnY HJ RnY total gastrectomy Whipple 91 pt 42 pt 85 pt RnY HJ RnY total Whipple Total Success blind end 95.6% 100% 100% 98.6% Time blind end (min) / Success diagnostic rate 100% 95.2% 98% 97.4% Overall success rate DB- ERCP 95.6% 95.2% 98% 96.1% Time for DB-ERCP (min) AE 1.1% Shimatani et al, UEG journal 5S, A44 9

10 OP106: EUS GUIDED GASTRO-GASTROSTOMY ASSISTED ERCP VS ENTEROSCOPY ASSISTED ERCP IN RNYGB Multicenter, comparative trial Kedia et al, GIE 2015 Bukhari et al, UEG journal 5S, A45 10

11 OP106: EUS GUIDED GASTRO-GASTROSTOMY ASSISTED ERCP VS ENTEROSCOPY ASSISTED ERCP IN RNYGB 160 patients, 5 centers Bukhari et al, UEG journal 5S, A45 11

12 OP359:INTRADUCTAL ABLATION DURING ENDOSCOPIC AMPULLECTOMY Retrospective analysis of patients undergoing endoscopic ampullectomy Rustagi et al, GIE 2016 Perez-Cuadrado et al, UEG journal 5S, A152 12

13 OP359:INTRADUCTAL ABLATION DURING ENDOSCOPIC AMPULLECTOMY Retrospective analysis of patients undergoing endoscopic ampullectomy If necessary, intraductal ablation was performed with wire-guided RF or wire-guided cystotome Retrospective analysis patients (58 years) EUS detected intraductal involvement in 16 (21.9%) Intraducactal ablation with cystotome (n=14) and RFA (n=2), followed with biliary and/or pancreatic stenting Complications 19.2% (AP, bleeding, perforation, ductal stricture) HGD (n=27, 37%) and adenocarcinoma (n=6, 8.2%) FU 23 months: Recurrence (16.4%) and surgery (3 pt) Multivariate analysis: only repeated endoscopic sessions >2 were associated with recurrence 13 Perez-Cuadrado et al, UEG journal 5S, A152

14 OP362: MISER RCT: MINIMALLY INVASIVE SURGERY VS ENDOSCOPY FOR NECROTIZING PANCREATITIS Patients with necrotizing pancreatitis Walled-off necrosis Minimally invasive surgery Laparoscopic KG with internal debridement or VARD Endoscopy Initial transmural drainage (single, multi gate or dual) And Debridement if necessary Primary end-points: Composite of major complications (MOF, bleeding or fistula)/death Secondary end points: Treatment success (early/mid/late) Bang et al, UEG journal 5S, A153 14

15 APPROACHES TO WON: TENSION TENSION trial: Multicenter RCT: 98 patients with infected WON Major complications or death during 6 m FU Endoscopic step-up approach ETD ETN if needed n = 51 Surgical step-up approach PCD VARD if needed n = 49 20% 28% NS Mortality 18% 13% NS No need for necrosectomy 41% 49% NS Pancreatic fistula 5% 32% p=0.001 LOS 36 d 69 d p=0.03 Dutch Pancreaittis Study Group, Abstract UEGW 2016 UEG. 2016

16 OP362: MISER RCT: MINIMALLY INVASIVE SURGERY VS ENDOSCOPY FOR NECROTIZING PANCREATITIS Minimally invasive surgery (n=32) Endoscopy (n=34) 40% required debridement MIS Endoscopy p Primary end point 34.4% 5.9% Treatment success Early Mid Late 53.1% 81.3% 84% 97.1% 100% 96.2% < Adverse effects 53.1% 41.2% 0.33 Mortality 6.3% 2.9% 0.61 LoS (days) Bang et al, UEG journal 5S, A153 16

17 OP363:LAMS VS PLASTIC DPT.ACT 1 - Cost-effective analysis for patients receiving LAMS vs DPT for WON - Simulation based on a pre-determined decision tree based on probabilities obtained from systematic review of the literature - Efficiency: Successful drainage without need for percutaneous or surgical intervention LAMS improves the effectiveness of endoscopic management of patients with WON Brewer-Guttierez et al, UEG journal 5S, 17 A153

18 P0252:LAMS VS PLASTIC DPT.ACT 2 Bang et al, UEG journal 5S, A248 18

19 Endoscopic management of WON (>20% necrosis) Interim analysis of ongoing RCT: EUS-guided drainage WON: Plastic vs LAMS LAMS (12) Plastic (9) AE (6):50% - Bleeding (n=3) - Buried stents (n=2) - After 3 weeks!! Bang et al, Gut 2016 Leeds et al, Gut 2016 AE (0):0% Trial still ongoing but extraction before 4 weeks

20 P0252:LAMS VS PLASTIC DPT.ACT 2 LAMS (n=31) Plastic (n=29) LAMS Plastic DPT p Procedure duration (min) <0.001 Resolution of preintervention of SIRS 44.4% 69.2% 0.38 Treatment success 96.3% 88% 0.34 Adverse effects Overall Stent related Number of re-interventions Readmissions 29% 34.5% 0.78 Extraction before 4 weeks After amendement, no differences were found (6.5% vs 6.9%) Bang et al, UEG journal 5S, A248 20

21 OP315: EUS GUIDED RFA FOR PREMALIGNANT PANCREATIC TUMORS Prospective multicenter French study (9/15-2/17) Patients with premalignant lesions who are unfit or refuse surgery: Side branch IPMNs with worrisome features Pancreatic NETs (<2cm) MCA EUS-guided RFA End points: Safety Efficacy at 1 year FU Barthet et al, UEG journal 5S, A248 21

22 Cytokine s RFA Heat injury Immunomodulation

23 OP315: EUS GUIDED RFA FOR PREMALIGNANT PANCREATIC TUMORS PATIENTS N= PNET:13.4 mm (8-20mm) CYSTIC T mm (9-60 mm) 3 14 Complications 3/30 (10%) AP PNET CYSTIC T. Delayed perforation Pancreatic duct stricture HEAD BODY TAIL HEAD BODY TAIL NSAIDS Antibiotics Aspirating cystic liquid before Barthet et al, UEG journal 5S, A248 23

24 OP315: EUS GUIDED RFA FOR PREMALIGNANT PANCREATIC TUMORS NETs: At 6 months: Significant response 82% 7 had complete necrosis or disappearance 2 a diameter decrease >50 %, 2 had a diameter decrease <50% 1 a complete failure Cystic lesions: At 6 months: Significant response 69% 7 complete resolutions, 2 PR diameter decrease >50% 1 partial response <50% 3 no response Mural nodes disappeared in 10 /12 cases Barthet et al, UEG journal 5S, A248 24

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