Doumit S. BouHaidar, MD Associate Professor of Medicine Director, Advanced Therapeutic Endoscopy Virginia Commonwealth University Overview Copyright American College of Gastroenterology 1
Incidence: 4 per 100 000 person years Prevalence: 42 per 100 000 50 % are related to alcohol however only 3 % of alcoholics develop chronic pancreatitis Smoking Genetic factors Ductal obstruction Idiopathic Copyright American College of Gastroenterology 2
Rebours, V Gut 2009 Strong association Often under estimated and not emphasized enough Duration & dose dependent If smoking is continued after recurrent acute pancreatitis attack >>>>>disease progress to chronic pancreatitis Increase mortality by 6 fold Sadr Gut 2012. Nojgaard, Pancreas 2011. Copyright American College of Gastroenterology 3
59 patients Mean f/u 51.6 months Progression of calcification by CT was more common in smokers Odds ratio [OR]= 9.987 p=0.006 Amount of smoking 1 ppd OR=6.051 >1 ppd OR 36.562 p=0.008 Lee JW. Gut Liver 2016 Most present with recurrent acute pancreatitis Over years and decades progressive changes appear in the pancreas Initial changes visible only by EUS Eventually they develop the triad Abdominal pain Exocrine pancreatic insufficiency Diabetes Copyright American College of Gastroenterology 4
EUS is the most sensitive tool for early diagnosis Ductal changes Parenchymal changes Presence of 4 or more criteria has a sensitivity of up to 91 % CT and MRCP are sensitive for advanced chronic pancreatitis Copyright American College of Gastroenterology 5
Management of exocrine insufficiency Management of endocrine insufficiency Management of pain Most difficult Management of complications Copyright American College of Gastroenterology 6
Alcohol cessation Tobacco cessation Extremely challenging in this population Patient with CP and are smokers were enrolled in smoking cessation program 0% quit rate after 18 months Han S. Pancreas 2016 Dose adjustment up to 90,000 USP of lipase / meal Start at lower dose 25,000 40,000 USP of lipase per meal and titrate up depending on clinical response Acid suppression is often needed Dominguez Munoz, E CGH 2011 Copyright American College of Gastroenterology 7
Incidence of diabetes is 50% Calcifications, smoking and age are predictors to develop diabetes Check fasting blood sugar Check HbA1c Beer, S. Pancreatology 2015 Pancreatic/visceral level Peripheral & spinal neuropathy level Cerebral level Demir, I. Langenbecks Arch Surg 2011 Copyright American College of Gastroenterology 8
Pancreatic/visceral level Peripheral & spinal neuropathy level Cerebral level Demir, I. Langenbecks Arch Surg 2011 Pancreatic/visceral level Peripheral & spinal neuropathy level Cerebral level Demir, I. Langenbecks Arch Surg 2011 Copyright American College of Gastroenterology 9
Causes of pain in chronic pancreatitis Chronic Pancreatitis Causes of Pain Ischemia Pseudocyst Duodenal and common duct obstruction PD Obstruction with Increased PD pressure Inflammation Neural inflammation Uncoated pancreatic enzymes Antioxidants Tricyclic antidepressants Gabapentin Pregabalin Tramadol Long term jejunal feeding Spinal cord stimulation Copyright American College of Gastroenterology 10
EUS Guided celiac block Injection of bupivacaine and triamcinolone Better to identify and target the celiac ganglia Copyright American College of Gastroenterology 11
Meta analysis (6 studies, n=221) : 51 % response rate Can be repeated in 3 6 months if effective Kauffman, M Gastroenterology 2008 Prospective double blinded, sham controlled study n=18 vs n=18 29% reduction of pain in CPB group vs 1% in sham group Morphine usage decreased in CPB group but not statistically significant This is still ongoing with goal of 40 in each arm Eisendrath, P. GIE 2014 Copyright American College of Gastroenterology 12
EUS Guided pseudocyst drainage 20 to 40 % of patients with CP develops this complication Drainage is indicated: Pain Infection Obstruction Copyright American College of Gastroenterology 13
First reported in 1989 Multiple reports documented high degree of success Chronic pancreatitis + Pseudocyst Success rate >90% Acute pancreatitis + Pseudocyst Success rate 70% Necrosis + Pseudocyst Success rate drops significantly Cremer, GIE 1989 Hookey GIE 2006 Technical success 90% Morbidity 10 to 15% Complete resolution 70 to 90% Recurrence rate 10 to 15% Copyright American College of Gastroenterology 14
New advances: Lumen Apposing Covered Self Expanding Metal Stents (LACSEMS) (Axios ECE) Advantage over other stents: Single step deployment Ability to perform endoscopic debridement Minimal to no stent migration Shah, R. CGH 2015 ERCP Copyright American College of Gastroenterology 15
What can be done: Sphincterotomy Balloon dilation Stone extraction Stenting What can be done: Sphincterotomy Balloon dilation Stone extraction Stenting Copyright American College of Gastroenterology 16
What can be done: Sphincterotomy Balloon dilation Stone extraction Stenting What can be done: Sphincterotomy Balloon dilation Stone extraction Stenting Copyright American College of Gastroenterology 17
Who to treat Intraductal stone in head of pancreas with large duct ESWL + ERP for large stone Single (dominant) stricture with large duct Selective cases with pancreas divisum Not effective Multiple strictures Stones in body and tail Small duct disease Copyright American College of Gastroenterology 18
Endotherapy Is an option for patients with severe comorbidities Bridge to surgery Success depends Number of strictures Location of the stricture (s) Length of the stricture (s) Stricture relapse after 2 year is 38% Conventional drainage procedures Copyright American College of Gastroenterology 19
Common indication Poorly controlled pain Duodenal biliary and pancreatic duct obstruction Symptomatic pseudocysts Cancer Whipple Puestow Frey procedure Beger procedure Copyright American College of Gastroenterology 20
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Dite et al, 2003 Prospective randomized Surgery better then endotherapy at 5 year follow up Cahen et al, 2007 Prospective randomized study Surgery better then endotherpay at 2 year follow up Ahmed, A Cochrane Database Syst Rev 2015 Copyright American College of Gastroenterology 23
Total Pancreatectomy with Islet Autotransplantation TP IAT TP IAT (Islet AutoTransplantion) TP AIT (Autologous Islet Transplant) TP ICT (Islet Cell Transplantation) Copyright American College of Gastroenterology 24
50 Copyright American College of Gastroenterology 25
Procurement Preservation Isolation Purification Tx Copyright American College of Gastroenterology 26
Significant improvement in pain Pain Score 10 p <0.0001 8 6 7% Before TP AIT Narcoticsdependent 4 2 Narcoticsfree 0 Pre TP/AIT 1 yr post TP/AIT 93% Narcotic Medication Morphine equivalent dose (mg/day) 250 200 150 100 50 0 Pre TP/AIT p <0.0001 1 yr post TP/AIT 71% 29% Courtesy of Dr Marlon Levy, 2015 1 yr after TP AIT Autologous islet transplantation is a viable treatment option for severe cases of Chronic Pancreatitis The outcomes following islet transplantation are excellent in terms of freedom from pain with acceptable glycemic control. Copyright American College of Gastroenterology 27
Fazlalizadeh, R. World J Transplant 2016 Alcohol and tobacco cessation can alter the progression of the disease Pain management is challenging due to complexity and different levels of pain Referral to tertiary care center is needed so therapy can be tailored in the early stages of the disease Copyright American College of Gastroenterology 28
EUS guided celiac plexus block minimally effective in reducing pain with no long term duration EUS guided pseudocyst drainage very successful and effective in carefully chosen patients. LACSEMS are great improvement toward efficient and effective therapy ERCP therapy is only effective in certain conditions Drainage surgery is more effective then endo therapy in reducing pain TP IAT is showing promising success in certain type of patients with CP Comparative studies of drainage procedures vs TP IAT are needed Copyright American College of Gastroenterology 29
Marlon Levy, MD Chair, transplant surgery at VCU Referral line (804) 828 6705 Copyright American College of Gastroenterology 30