ESPEN Congress Brussels 2005

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1 ESPEN Congress Brussels 2005 Therapeutic endoscopy of pancreatic diseases. How endoscopy may improve nutrition? Myriam Delhaye

2 Therapeutic endoscopy of pancreatic diseases. How endoscopy may improve nutrition? Myriam Delhaye Medico-surgical Department of Gastroenterology Erasme Hospital Brussels - Belgium 27th ESPEN Congress, Brussels, Belgium August 2005

3 Acute pancreatitis Definition Acute inflammatory process of the pancreas may involve Peripancreatic tissues Remote organ systems Symposium of Atlanta 1992 Bradley, Arch Surg 1993; 128: 586

4 Acute pancreatitis Mortality Mild in 80% of cases < 1% Severe in 20% of cases Sterile necrosis 10% Infected necrosis 25% Atlanta criteria Organ failure Local complications Ranson's score 3 Apache II score 8 CRP 15 mg/dl CTSI 7

5 Severe Acute pancreatitis Prophylactic antibiotics Nutritional support Endoscopic therapy

6 Severe Acute pancreatitis Nutritional support: TEN vs TPN Infection p = ,45 RR Complications other than infection 0.61 NS Surgical interventions p = ,48 Mortality NS 0,66 1 Length of stay 2.9 d ( ) p < 0.01 Meta analysis of 6 RCT (n = 263 patients) Marik, BMJ 2004; 328: 1407

7 Severe Acute pancreatitis Nutritional support TEN Nasogastric tube No radiological assistance endoscopic No change in - mortality - total hospital stay - days in ICU Nasojejunal tube Endoscopic placement Risk of dislocation No adverse effect - on acute phase response - on pain, analgesics Eatock, Am J GE 2005; 100: 432

8 Acute pancreatitis Indications for endoscopic treatment Biliary AP: EBS + extraction of CBD stones Fluid collections: drainage procedures

9 Predicted mild Biliary AP Predicted severe Cholangitis Jaundice Improving No cholangitis No jaundice No CBD stone Cholecystectomy + IOC Unfit for cholecystectomy Biliary symptoms or already suggesting CBD stones cholecystectomised No improvement after 48 h Elective EBS Early EBS morbidity mortality If CBD stones present at IOC EBS

10 Acute pancreatitis Fluid collections: drainage procedures Necrosis (> 30%) Clinical deterioration organ failure persistent symptoms > 7d clinical suspicion sepsis CT-guided percutaneous FNA of pancreatic necrosis Sterile Infected Supportive care Adapt antibiotherapy MRI/S-MRCP

11 Acute pancreatitis Fluid collections: drainage procedures MRI/S-MRCP Partial MPD rupture Organized liquefied necrosis Transpapillary stent bridging the rupture NO YES Surgical necrosectomy Endoscopic transmural > 2 4 W after onset drainage Technical/Clinical success 72% Telford, GE 2002; 56: 18 Baron, GE 1996; 111: 755 Baron, GE 2002; 56: 7

12 67 y.o. man with biliary AP ERCP + ES + removal of a CBD stone within 24h of symptom onset T 2 MRI at admission T 2 MRI 6 w after onset CE-CT 6 w after onset C D E F Transmural drainage of the infected pancreatic collection

13 Chronic pancreatitis Definition Relapsing or continuing inflammatory disease of the pancreas irreversible morphologic changes pain ± loss of exocrine/ endocrine function International Workshop on Pancreatitis, Cambridge 1983

14 Causes of malnutrition in patients with CP calorie intake due to pain after meals Pancreatic exocrine insufficiency fat malabsorption late in the course of CP < large functional reserve synthesis/secretion of lipase [H CO3] secretion low intraduodenal ph lipase activity extrapancreatic lipolysis marginal Pancreatic endocrine insufficiency Coexistent alcoholism, liver disease

15 Nutritional management in CP Appropriate management of pain analgesics 30 min before meals endoscopic therapy

16 Severe chronic pancreatitis Parenchyma decreased compliance Ducts obstruction stones 18% strictures 47% both 32% Tissue hypertension Ischemia pain oxydative stress mediators of inflammation fibrosis Pancreatic fibrogenesis NO CURATIVE TREATMENT AVAILABLE

17 Selection of patients with severe CP for endoscopic therapy Obstruction of the MPD by stones/strictures/both Fluid collections < downstream ductal obstruction < disruption of the MPD Obstruction of the CBD < fibrotic changes in the pancreas < compression by a pancreatic pseudocyst

18 Pain and MPD obstruction Endotherapy = 1st choice of treatment

ESWL (40% of cases) 3000-5000 Shock waves mj/mm 2 0.28 = 3 0.33 = 4 0.37 = 5 0.42 = 6 0.47 = 7 0.

19 ESWL (40% of cases) Shock waves mj/mm = = = = = = < 5 if ERCP follows Chronic pancreatitis Pain and MPD obstruction 1st step of endotherapy = fragmentation of obstructive pancreatic ductal stones Bidimensional X ray focusing system

ESWL 3000-5000 Shock waves mj/mm 2 0.28 = 3 0.33 = 4 0.

54 = 8 4-8 < 5 if ERCP follows Chronic pancreatitis Pain

20 ESWL Shock waves mj/mm = = = = = = < 5 if ERCP follows Chronic pancreatitis Pain and MPD obstruction 1st step of endotherapy = fragmentation of obstructive pancreatic ductal stones

21 After ESWL Chronic pancreatitis Pain and MPD obstruction 2nd step of endotherapy: EPS, stone extraction, NPC EPS Stone extraction NPC

22 Cannulatome Torque device Position 1 Position 2

24 10F Teflon Bougie Maxforce Balloon 6mm x 4cm Soehendra stent retriever

25 Pancreatic stenting for severe CP

27 Chronic pancreatitis Pain and MPD obstruction 3rd step of endotherapy: pancreatic stenting (50-60% of patients with CP)

28 Technical results of MPD drainage Initial technical success (86%): decrease in MPD ± complete clearance ESWL = the only independent predictive factor for technical success Dumonceau, GIE 1996; 43: 547

29 Pain and MPD obstruction in CP Clinical results of endoscopic therapy Short-term FU < 2 y Clinical success 82-94% Predictive factors Technical success of ductal drainage ( MPD ) Medium-term FU 2-5 y 48-84% Short duration of disease Low frequency of pain Absence of MPD stricture Long-term FU 14 y 66% Short duration of disease No current smoking ESWL + endotherapy as early as possible in the course of CP

30 Which test for malabsorption screening in CP? Correlation between the acid steatocrit and the TBT 60 patients with CP (10 mild, 50 severe) Acid steatocrit (AS) = fatty layer / (fatty layer + solid layer) x 100 fatty layer water layer Acid Triolein Mean values steatocrit Breath for AS Test compared to TBT results ingestion 24h stools, of (n=60 a normal standard CP) diet lipid-rich ( test g fat/d) meal 80 homogenization (30 g) containing 5 µci of 14 p< C glycerol 70 sample trioleatecentrifugation in acid environment 60 % lipid 14 CO phase 2 exhaled on dry compared feces in volumetric to the total % 50 Normal TBT (n=17) N: CO< 2 10% of the sample 40 N: > 3% Acid Steatocrit value (%) Pathological TBT (n=43) solid layer AS = 60% AS = 12% AS = 7% Dumasy et al, Am J GE 2004; 99: 1350

31 Evolution of exocrine dysfunction 100 Proportion of patients (%) to 5 (n=27) 6 to 10 (n=15) >10 (n=18) Abnormal steatocrit Clinical steatorrhea Present when AS 30% Sens 38% Spec 100% Duration of CP (years) Pancreatic exocrine insufficiency underestimated in patients with CP when its assessment is based on the presence of clinical steatorrhea Dumasy et al, Am J GE 2004: 99: 1350

32 2,5 Impact of malabsorption on BMI Loss of BMI per year (kg/m2/y) 2 1,5 1 0,5 0 NS p<0.03 No malabsorption (n=13) Treated malabsorption (n=19) Untreated malabsorption (n=28) (24 without clinical steatorrhea) Ammann, GE, 1999; 116: 1132 p<0.03 Undetected Untreated malabsorption harmful effect on weight loss Dumasy et al, Am J GE 2004; 99: 1350

33 Impact of endotherapy on the pancreatic Test exocrine function in patients with CP Patients Literature data Improved (%) Worsened (%) No change (%) TBT Steatorrhea FU (m) Delhaye, GE 1992 PABA test Ohara, AJGE 1996 Steatorrhea Adamek, Gut 1999 Steatorrhea Brand, AJGE 2000 Diarrhea Rösch, Endoscopy 2002

34 Exocrine pancreatic function after endotherapy endotherapy in CP postponed the functional exocrine impairment for about 10 years

35 Predictive factors for exocrine insufficiency Developing steatorrhea Yes n = 18 No n = 22 Alcoholic etiology 89% 55% p=0.018 Recurrent symptomatic ductal obstruction further ESWL 72% 36% p=0.025 N hospit. for pain/y p=0.024 Duration of endotherapy (m) p=0.021 exocrine pancreatic function dependent on early relief of ductal obstruction

36 Impact of endotherapy on the pancreatic endocrine function in patients with CP Literature data Patients Improved (%) Worsened (%) No change (%) FU (m) Delhaye, GE Ohara, AJGE Rösch, Endoscopy 2002

37 Risk factors for diabetes mellitus in CP n: 453 patients; surgery: n=231; FU: 7 ± 6.8 y RR 3,2 2,4 1,7 1 Alcoholic cause of CP Pancreatic calcifications Distal pancreatectomy 0,8 Pancreatic drainage p=0.04 p<0.001 p< NS Malka, GE 2000; 119: 1324

38 Endocrine pancreatic function after endotherapy endotherapy in CP did not prevent the appearance of DM

39 Predictive factors for endocrine insufficiency Developing diabetes Yes n = 25 No n = 15 Alcoholic etiology* 84% 40% p=0.007 Age at onset (y) p=0.016 Age at study entry (y) p=0.002 Amount of tobacco (pack-years) p<0.001 *Significant by multivariate analysis endocrine pancreatic function dependent on alcohol consumption habits role in development of fibrosis

40 Conclusions Severe acute pancreatitis Nutritional support TEN > TPN Nasogastric feeding Ξ Nasojejunal feeding Early ERCP + EBS in severe biliary AP Endoscopic transmural drainage for organized liquefied necrosis 4 W after onset symptomatic infected Transpapillary bridging stent for partial MPD rupture

41 Conclusions Severe chronic pancreatitis Pain & ductal obstruction ENDOTHERAPY = first choice long-term benefit for about 2/3 of patients hospit. rate overtime delaying functional exocrine impairment good clinical outcome associated with cessation or absence of smoking alcohol abuse risks of diabetes mellitus steatorrhea

42 Acknowledgements Department of Gastroenterology M. Arvanitakis M. Baize Pr. M. Cremer Pr. J. Devière O. Le Moine A. Vandermeeren Department of Radiology C. Matos D. Van Gansbeke M. Zalcman A. Van Gossum G. Verset Scientific Secretary Department of Digestive Surgery J. Closset Pr. M. Gelin C. Piesen

The role of ERCP in chronic pancreatitis

The role of ERCP in chronic pancreatitis Marianna Arvanitakis Erasme University Hospital, ULB, Brussels, Belgium 10 th Nottingham Endoscopy Masterclass SPEAKER DECLARATIONS This presenter has the following