7/11/2017. We re gonna help a lot of people today. Biliary/Pancreatic Endoscopy. AGS July 1-2, Kenneth M. Sigman, MD

Transcription

1 Biliary/Pancreatic Endoscopy AGS July 1-2, 2017 Kenneth M. Sigman, MD We re gonna help a lot of people today 1

2 2

3 3

4 4

5 Cannulation It all starts with cannulation Double Wire Cannulation Difficult cannulations Relatively atraumatic Remember ampullary anatomy 5

6 Biliary Strictures Biliary Strictures Benign Post-op Sclerosing cholangitis Stone related SOD Malignant Pancreatic Ca Ampullary Ca Cholangio Ca Metastatic Ca Autoimmune cholangitis Choledochal cysts Mirizzi syndrome Chronic pancreatitis Lymphoma/Sarcoma GB Ca Clinical Presentation Jaundice- elevated LFTs Pain- usually RUQ Fever N/V Wgt loss 6

7 Clinical Evaluation Blood tests- LFTs, CEA, CA19-9 U/S CT MRI/MRCP EUS ERCP EUS Relatively noninvasive Can assess multiple organs and LNs Targeting for FNA OSP/IRP- instant results Biliary strictures are difficult to assess ERCP for Strictures Imaging of both ducts Brush cytology & biopsies Direct visualization with Spyglass Balloon dilation Stent placement Polyethylene/plastic Metal mesh 7

8 Stricture Diagnosis ERCP Brush cytology % sensitivity Duct biopsy % sensitivity Direct Cholangioscopy/ targeted biopsy % sens EUS/FNA Pancreatic mass % sensitivity Biliary strictures % sensitivity *- other modalities- intraductal US, CLE Plastic Biliary Stent 8

9 Hans Wallsten Biliary Stents Polyethylene french Change every 3 4 months Metal expandable Up to 30 french Not removable (maybe) 9

10 Polyethylene Stents Good short-term relief of bile duct obstruction Easily placed and removed Inexpensive Effective in healing bile leaks and benign strictures Polyethylene Stents Limited diameter 11.5 French Occlude easily Additional ERCP s drive up cost Plastic Stent Randomized Study Occlusion Rates Prat Schmassann Knyrim Davids n - 33 n - 70 n - 28 n - 56 P<.001 P=

11 Metal Stents Good long-term relief of bile duct obstruction Easily placed Large diameter (30 French) prolongs patency Fewer repeat ERCP s lower cost Approved for malignant & non-obstruction Covered or Uncovered Covered Less tissue ingrowth Migration (3-13%) Advantage of patency No significant increase of pancreatitis/cholecystitis Removable More expensive Uncovered More tissue ingrowth No migration Less patency time Not removable Less expensive Intrahepatics Stents for Benign Strictures 2-10Fr plastic stents x 12 months- 85% ERCP with stent change Q 3mos = 5 ERCPs Fr FC metal stent x 6 months- 85% ERCP with stent insertion & removal = 2 ERCPs 11

12 Benign bile duct stricture Stents for Malignant Strictures Plastic stents- temporary, bridge to surgery Metal stents- longer term palliation 12

13 Recurrent Pancreatitis ETOH, biliary(stones or sludge), trig, Ca++, meds Autoimmune Divisum Microlithiasis SOD IPMN Hereditary Occ malignancy Diagnostic Methods US CT MRI/MRCP EUS Lab Data ERCP Recurrent Pancreatitis ETOH, biliary(stones or sludge), trig, Ca++, meds Autoimmune Divisum Microlithiasis SOD IPMN Hereditary Occ malignancy 13

14 Relapsing Pancreatitis Microlithiasis Sludge Calcium bilirubinate or cholesterol crystals Microscopy of bile aspirate Best obtained at ERCP Cholesterol Crystals Microlithiasis 2 good studies Lee NEJM 1992 Ros Gastroenterology 1991 About 60% with idiopathic pancreatitis had crystals Significant reduction in recurrent episodes with ES or cholecystectomy 14

15 Ruggero Ferdinando Antonio Guiseppe Vincenza Oddi Ampullary Sphintcer Anatomy Type I Clinical Classifications of pancreatic SOD Pancreatic type pain PD >3mm Delayed drainage time Elevated Pancreatic enzymes Type II Pancreatic type pain PD >3mm Delayed drainage time Elevated Pancreatic enzymes Type III > All > three present One or two present Pancreatic type pain Only 15

16 Results of Sphincterotomy in Pancreatic SOD Type I pts 90% improvement Type II pts 80% improvement with elevated SOP 33% improvement with normal SOP Type III pts 25% improvement Relapsing Pancreatitis Pancreas Divisum Failure of dorsal and ventral duct to fuse Prevalence 5 10 % Relative obstruction of accessory papilla Improvement with ES or stent Accessory Papilla Cannulation 16

17 Ventral Pancreas Dorsal Pancreas What to expect from your ERCP endoscopist Kind, courteous, friendly Rapid response Always on time Have multiple scopes and instruments > 95% successful pancreatic and bile duct cannulation Low complication rates > 90% Relief of obstruction Successful stone extraction Diagnosing malignant vs benign lesions & appropriate tx * Always have a plan B & sometimes C,D,E 17

18 Putting together the pieces Pathology Surgical Imaging DX LabTests & TX Signs & Endoscopy Symotoms 18