Does it matter what we drain?

Endoscopic Management of Pancreatic Fluid Collections Shyam Varadarajulu, MD Medical Director Center for Interventional Endoscopy Florida Hospital, Orlando Does it matter what we drain? Makes all the difference! 1

Clinical Outcomes in 211 patients Treatment success % Pseudocyst + Abscess = 154 93.5% Necrosis N = 57 63.2% p <0.0001 Complications % 5.2% 15.8% 0.02 Median Reinterventions (IQR) 1 (1-1) 1 (1-2) 0.02 Median length of stay (IQR) 2 (1-4) 5 (2-17) < 0.0001 Varadarajulu S: J GI Surg 2011 1992 Atlanta 2007 APCWG Acute fluid collection (<4 weeks after onset of pancreatitis) Acute fluid collection (AFC) Pancreatic necrosis Infected necrosis Acute necrotic pancreatic/ peripancreatic/both collection (ANC) Sterile Infected (>4 weeks after onset of pancreatitis) Pancreatic pseudocyst (usually has increased amylase/lipase activity) Pancreatic pseudocyst Sterile Pancreatic abscess Infected Walled-off necrosis (WON) (mature ANC with defined wall) Pancreatic Both Extrapancreatic Sterile or Infected 2

CT Pancreatic Pseudocyst Well circumscribed, thin walled, homogeneous low attenuation collection Adjacent to, occasionally within, an otherwise normal appearing pancreas. CT Pancreatic Pseudocyst Well circumscribed, thin walled, homogeneous low attenuation collection Adjacent to, occasionally within, an otherwise normal appearing pancreas. 3

MRI Assessment Geographic areas of altered T1 signal pancreatic necrosis depicted on CECT High signal intensity on unenhanced T1 FS SGE hemorrhage and correlates with severity MRSI=CTSI using dynamic 3D T1 SGE gado enhanced images PD duct eval using MRCP T2 MRI superior to CT solids T2 T1 SGE MRCP Lecesne Radiology 1999;211:727-735 Pamuklar Magn Reson Clin NA 2005;13:313-330 Arvanitakis Gastroenterology 2004;126:715-723 Morgan Radiology 1997;203:773-778. MRI Assessment Geographic areas of altered T1 signal pancreatic necrosis depicted on CECT High signal intensity on unenhanced T1 FS SGE hemorrhage and correlates with severity MRSI=CTSI using dynamic 3D T1 SGE gado enhanced images T1 SGE Lecesne Radiology 1999;211:727-735 Pamuklar Magn Reson Clin NA 2005;13:313-330 Arvanitakis Gastroenterology 2004;126:715-723 Morgan Radiology 1997;203:773-778. 4

MRI Assessment Geographic areas of altered T1 signal pancreatic necrosis depicted on CECT High signal intensity on unenhanced T1 FS SGE hemorrhage and correlates with severity MRSI=CTSI using dynamic 3D T1 SGE gado enhanced images PD duct eval using MRCP T1 SGE MRCP Lecesne Radiology 1999;211:727-735 Pamuklar Magn Reson Clin NA 2005;13:313-330 Arvanitakis Gastroenterology 2004;126:715-723 Morgan Radiology 1997;203:773-778. MRI Assessment Geographic areas of altered T1 signal pancreatic necrosis depicted on CECT High signal intensity on unenhanced T1 FS SGE hemorrhage and correlates with severity MRSI=CTSI using dynamic 3D T1 SGE gado enhanced images PD duct eval using MRCP T2 MRI superior to CT solids T2 T1 SGE MRCP Lecesne Radiology 1999;211:727-735 Pamuklar Magn Reson Clin NA 2005;13:313-330 Arvanitakis Gastroenterology 2004;126:715-723 Morgan Radiology 1997;203:773-778. 5

Pseudocysts 6

RT Comparing EUS vs. EGD EUS EGD p Technical success US 100% 33.3% <0.001 S. Korea 96.3% 66.7% 0.01 Treatment success US S. Korea 100% 96.2% 86.7% 83.3% 0.48 NS Complications US S. Korea 0 3.7%* 13.3% 14.8% 0.48 >0.05 US Trial: Death (n=1), severe bleeding (n=1) S. Korea Trial: bleeding (n=3), perforation (n=1), * stent migration (n=1) Varadarajulu S: GI Endoscopy 2008; Moon SH: Endoscopy 2009 RT of Endoscopy vs. Surgery Endoscopy N = 20 Surgery N = 20 p Technical success % 100 100 1 Treatment success % 95 100 1 Complications % 0 2 0.49 Recurrence 0 1 Median LOS (days) 2 6 0.001 Cost US$ 7011 15052 0.005 QOL + - Varadarajulu S: Gastroenterology 2013 7

Conclusions EUS: Drainage modality of choice No evidence for use of SEMS Endoscopy comparable to surgery: Less costly Better QOL Shorter length of hospital stay Pancreatic Pseudocyst: Stent Relationship Characteristics (N=122) PFC Type Acute 23.6% Chronic 76.4% Stent Diameter 7 Fr: 10 Fr 77 (63.2%) 45 (36.8%) Outcomes: > 1 intervention Variable 95% CI p PFC size 0.95 0.94 Location 1.48 0.65 1 >1 36 (27.6%) 86 (63.4%) Type 0.58 0.47 No. stents Median 1 (IQR 1-2) Stent size 3.9 0.17 Duration Minutes 25.7 (13.9) Stent No. 1.29 0.71 Rx success 98.3% Perman. 0.89 0.87 Bang JY, Varadarajulu S: Surg Endosc (In press) Prasad G, Varadarajulu S: GIE Clinics 2013 8

Pancreatic Pseudocyst: Stent Relationship Characteristics (N=122) PFC Type Acute 23.6% Chronic 76.4% Stent Diameter 7 Fr: 10 Fr 77 (63.2%) 45 (36.8%) Outcomes: > 1 intervention Variable 95% CI p PFC size 0.95 0.94 Location 1.48 0.65 1 >1 36 (27.6%) 86 (63.4%) Type 0.58 0.47 No. stents Median 1 (IQR 1-2) Stent size 3.9 0.17 Duration Minutes 25.7 (13.9) Stent No. 1.29 0.71 Rx success 98.3% Perman. 0.89 0.87 Bang JY, Varadarajulu S: Surg Endosc (In press) Prasad G, Varadarajulu S: GIE Clinics 2013 Pancreatic Pseudocyst: Stent Relationship Characteristics (N=122) Outcomes: > 1 intervention PFC Type Acute 23.6% Variable 95% CI p Chronic 76.4% After adequate dilation, placement of a single 7 or 10Fr stent is sufficient for successful treatment of uncomplicated PFC size pancreatic 0.95 pseudocysts 0.94 Stent 7 Fr: 77 (63.2%) Diameter 10 Fr 45 (36.8%) Location 1.48 0.65 1 >1 36 (27.6%) 86 (63.4%) Type 0.58 0.47 No. stents Median 1 (IQR 1-2) Stent size 3.9 0.17 Duration Minutes 25.7 (13.9) Stent No. 1.29 0.71 Rx success 98.3% Perman. 0.89 0.87 Bang JY, Varadarajulu S: Surg Endosc (In press) Prasad G, Varadarajulu S: GIE Clinics 2013 9

Pancreatic Pseudocyst: Stent Relationship Characteristics (N=122) Outcomes: > 1 intervention PFC Type Acute 23.6% Variable 95% CI p Chronic 76.4% After adequate dilation, placement of a single 7 or 10Fr stent is sufficient for successful treatment of uncomplicated PFC size pancreatic 0.95 pseudocysts 0.94 Stent 7 Fr: 77 (63.2%) Diameter 10 Fr 45 (36.8%) Location 1.48 0.65 No. stents Duration 1 >1 Median Minutes What is adequate dilation? 36 (27.6%) Esophagus 86 (63.4%) Type 6mm 0.58 0.47 Stomach 12-15mm Duodenum: 1 (IQR 1-2) Stent 8-12mm size 3.9 0.17 Jejunum: 6mm 25.7 (13.9) Stent No. 1.29 0.71 Rx success 98.3% Perman. 0.89 0.87 Bang JY, Varadarajulu S: Surg Endosc (In press) Prasad G, Varadarajulu S: GIE Clinics 2013 WOPN 10

Treatment Phase I: Treatment Success (Necrosis resolution) Phase II: Recurrence (> 12 months) Treatment of Pancreatic Necrosis Assessment 1. V.S; Fluid resuscitation; Pain Control; Supportive Rx Organ Failure 2. Contrast-enhanced CT 3. ENTERAL FEEDING 4. NO ANTIBIOTICS ERCP 1. Cholangitis 2. Obs. stone Necrotizing Pancreatitis Sterile Necrosis 1. Conservative Rx 2. Exceptions: Compartment syndrome GI or Biliary Obstruction Transmural Drainage Delay Rx for 3-4 weeks Wall-off Infective Necrosis IF needed Step-Up Approach Necrosectomy 11

Wall-off Time? Brunschot SV: CGH 2012 Treatment of WOPN Surgery N=45 Step-Up N=43 p Complications 69% 40% 0.006 Organ Failure 40% 12% 0.002 Death 19% 16% 0.70 Van Santvoort HC: NEJM 2010 12

Treatment of WOPN Surgery N=45 Step-Up N=43 p Complications 69% 40% 0.006 Organ Step-up Failure : s/p transmural 40% drainage 12% = 35% no further 0.002 Rx Death 19% 16% 0.70 Van Santvoort HC: NEJM 2010 Treatment of WOPN Surgery N=45 Step-Up N=43 p Complications 69% 40% 0.006 Organ Step-up Failure : s/p transmural 40% drainage 12% = 35% no further 0.002 Rx Death 19% 16% 0.70 Van Santvoort HC: NEJM 2010 13

Treatment of WOPN Surgery N=45 Step-Up N=43 p Complications 69% 40% 0.006 Organ Step-up Failure : s/p transmural 40% drainage 12% = 35% no further 0.002 Rx Death 19% 16% 0.70 Van Santvoort HC: NEJM 2010 Treatment of WOPN Surgery N=45 Step-Up N=43 p Complications 69% 40% 0.006 Organ Step-up Failure : s/p transmural 40% drainage 12% = 35% no further 0.002 Rx Death 19% 16% 0.70 Endoscopic Necrosectomy/Surgery Van Santvoort HC: NEJM 2010 14

Endoscopic Necrosectomy Study Clinical Complications Mortality success GEPARD (N=93) 80% 26% 7.5% US Multi-Center 91% 14% 5.8% Seifert H: GUT 2009 Gardner T: GI Endosc 2011 Endoscopic Necrosectomy 15

Endoscopic Step-up Approach D I F F I C U L T Y Suboptimal Response Percutaneous Necrosectomy WOPN >12cm Hybrid Technique (MTGT + 24Fr Per. Ctht Catheter for Flank kextn.) WOPN < 12cm Standard Technique (stents and 7Fr drainage catheter) 1. Conventional Drainage 16

2. Multiple Transluminal Gateway Technique (MTGT) 2. Multiple Transluminal Gateway Technique (MTGT) 17

2. Multiple Transluminal Gateway Technique (MTGT) 2. Multiple Transluminal Gateway Technique (MTGT) 18

MTGT MTGT + 24Fr P. Catheter (Flanks) 19

MTGT + 24Fr Perc. Catheter 3. Percutaneous Necrosectomy 20

Percutaneous Necrosectomy WOPN 100 patients 10 years Mean size mm DPDS MTGT/Perc. Necr. Med. Interventions Mean hospital stay Group I=47 Standard (2004-2009) 114 65% 89.4% 1.4 12.4 Group II=53 Step-up (2010-2013) 115 64% 56.6% 1.5 11.4 p 0.700 0.99 <0.001 0.53 0.155 21

Treatment Success Varadarajulu S: DDW 2014 Treatment Phase I: Treatment Success (Necrosis resolution) Phase II: Recurrence (> 12 months) 22

Recurrence of PFCs after Treatment Success 20-30% Palaez-Luna M GI Endosc 2008; Tann M J CAT 2003 Disconnected Pancreatic Duct Syndrome 23

Disconnected Pancreatic Duct Syndrome PFC Recurrence 24

Permanent Indwelling Transmural Stents PFC recurrence + (N=5) PFC recurrence - (N=48) p Permanent Stent + 0 29 (100%) 0.015 Permanent Stent - 5 (20.8%) 19 (79.2%) Varadarajulu S: JGH 2013 Take Home Message Treatment Success: Pseudocyst Drainage, > 90% 1 WOPN, 76% 2 (Hybrid approach 90%) What we need: Multidisciplinary Care! Disconnected Pancreatic Duct Syndrome: Permanent indwelling stents 3 1 Varadarajulu S, J GI Surg 2011 3 Varadarajulu S, JGH 2013 2 Varadarajulu S, DDW2014 25

Minimally Invasive Surgery vs. Endoscopy Randomized (MISER) Trial for WOPN Florida Hospital, UAB, John s Hopkins 1-800-NECROSIS 26

September 3-5, 2014 Course Directors: Dr. Shyam Varadarajulu Dr. Muhammad Hasan Dr. Shantel Hebert-Magee Dr. Robert Hawes Invited Faculty: Dr. Pierre Deprez, Belguim Dr. Paul Fockens, Netherlands Dr. Takao Itoi, Japan Dr. Darshana Jhala, USA Dr. Michael Levy, USA Dr. Fauze Maluf-Filho, Brazil Dr. Anand Sahai, Canada Dr. Peter Vilmann, Denmark Course Summary: Live case demonstrations Didactic lectures, breakfast sessions, literature update and special focus on EUS-Cytopathology Dedicated hands-on lab focusing on key areas in diagnostic and therapeutic EUS Register Now www.fhcieevents.com EUS2014 19 th International Symposium on Endoscopic Ultrasonography September 18-19, 2014: International Symposium September 20, 2014: Basic Training and Tutorials ITC Grand Chola, Chennai, India www.eus2014.org 27