Endoscopic Management in Acute Pancreatitis Stuart Sherman, M.D. - - PDF document

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Endoscopic Management in Acute Pancreatitis Stuart Sherman, M.D. - - PDF document

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Stuart Sherman, MD, FACG Endoscopic Management in Acute Pancreatitis Stuart Sherman, M.D. Indiana University Medical Center Indianapolis, Indiana Endotherapy of Pancreas Disease ERCP traditionally avoided for pancreas indications because

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Stuart Sherman, MD, FACG

Endoscopic Management in

Acute Pancreatitis

Stuart Sherman, M.D. Indiana University Medical Center Indianapolis, Indiana

Endotherapy of Pancreas Disease

  • ERCP traditionally avoided for pancreas

indications because of concern for procedure-related pancreatitis

  • Two developments led to more

widespread use

–Recognition of relative safety in setting of

gallstone pancreatitis

–Development of endoscopic and

pharmacologic methods to decrease rate

  • f post-ERCP pancreatitis
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Stuart Sherman, MD, FACG

Endoscopic Therapy of Pancreatic Disease

  • Acute pancreatitis

– Gallstones – Sphincter of Oddi dysfunction – Pancreas divisum – Choledochocele – Tumor

  • Chronic pancreatitis

– Strictures – Stones – CBD stricture

  • Complications of pancreatitis

– Pseudocysts and fistula – Necrosis

Gallstone Pancreatitis

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Stuart Sherman, MD, FACG

Gallstone Pancreatitis: Endoscopic Rx

  • Prospective randomized controlled trial
  • Gallstones suspected by US and/or

biochemical tests

  • 121 patients Rx’d conventionally or by urgent

(< 72 hr) ERCP/ES and stone extraction

  • Patients stratified according to predicted

severity based on modified Glasgow criteria

  • Neoptolemos. Lancet 1988;2:975.

Urgent ERCP (<72 hr) vs Conventional Rx For Acute Gallstone Pancreatitis

Group / Treatment N Complications Death Mild – Conventional 34 12% 0% Mild – ERCP/ES 34 12% 0% Severe – Conventional 28 61%* 18% Severe – ERCP/ES 25 24% 4%

*p=0.007 (vs conventional)

  • Neoptolemos. Lancet 1988;2:979
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Stuart Sherman, MD, FACG

Group / Treatment N Overall Complications Biliary Sepsis Death Mild – Conventional 35 17% 11% 0% Mild – ERCP/ES 34 18% 0% 0% Severe – Conventional 28 54% 29% 18%* Severe – ERCP/ES 30 13% 0% 3%

*p=0.07 (vs conventional); **p=0.003

  • Fan. NEJM 1993;328:228

Emergent ERCP (< 24 hr) vs Conventional Rx For Gallstone Pancreatitis

**

Acute Gallstone Pancreatitis: Endoscopic Rx

  • 238 gallstone pancreatitis patients

randomized within 72 hours of symptom

  • nset to ERCP/ES (n=126) or conservative

Rx (n=112)

  • Patients with biliary obstruction

(>5 mg/dl) or cholangitis excluded

  • Severity of AP based on modified Glasgow

criteria

Fölsch. NEJM 1997;336:237.

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Stuart Sherman, MD, FACG

ERCP vs Conventional Rx For Acute Gallstone Pancreatitis

Treatment Group Complication Conservative (n=112) ERCP/ES (n=126) p value Pancreatic 22% 23% .98

  • Resp. Failure

5% 12% .03 Jaundice 11% 1% .02 Cholangitis 12% 14% .81 Renal Failure 4% 7% .10 Total Complications 51% 46%* .54 Death from ABP 4% 8%* .16

*No difference based on severity of AP. Fölsch. NEJM 1997;336:227.

Gallstone Pancreatitis – Role of ERCP 8 RCT + 6 meta-analysis

1. Early ERCP in the absence of coexisting cholangitis or biliary obstruction DOES NOT lead to a reduction in mortality and local or systemic complications 2. Patient outcomes are not dependent on predicted severity

  • f pancreatitis

3. ERCP is not indicated for gallstone pancreatitis alone regardless of pancreatitis severity 4. ERCP should be done when gallstone pancreatitis is complicated by biliary obstruction or cholangitis

Fogel, Sherman NEJM (In Press)

Conclusions

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Stuart Sherman, MD, FACG

Pancreas Divisum

  • Most common congenital variant of

PD anatomy

  • Occurs when dorsal and ventral ducts

fail to fuse

  • With duct nonunion, the major portion
  • f the exocrine juice drains into the

duodenum via the dorsal duct and minor papilla

  • Common cause of unexplained

recurrent pancreatitis

Pancreas Divisum

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Stuart Sherman, MD, FACG

Pancreas Divisum Minor Papilla

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Stuart Sherman, MD, FACG

  • Aim to alleviate the outflow
  • bstruction
  • Methods: dilation, ES, stenting

Pancreas Divisum: Endoscopic Therapy Dorsal Duct Stent

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Stuart Sherman, MD, FACG

Minor Papilla ES Pancreas Divisum

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Stuart Sherman, MD, FACG

Minor Papilla Rx for Pancreas Divisum and ARP 12 studies 1986-2009

  • No. pts.

Follow-up (mos) Improved

241 30 76%

Pancreas Divisum and ARP: Results for Minor Papilla Stenting

Therapy F/U (mo) Hosp. ER Number w/panc. Improved Stent (n=10) 29 1 9 (90%) Control (n=9) 32 5* 2 7* 1 (11%)*

P<.05; Lans. GI Endosc 1992;38:430

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Stuart Sherman, MD, FACG

  • Patients with pancreas divisum and

acute recurrent pancreatitis are good candidates for minor papilla therapy

  • Long-term outcome studies and

further RCTs of endoscopic therapy are needed

Conclusion: ARP Due to Pancreas Divisum

Sphincter of Oddi Dysfunction

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Stuart Sherman, MD, FACG

Sphincter of Oddi Triple Lumen Catheter

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Stuart Sherman, MD, FACG

Sphincter of Oddi Manometry SO Manometry Tracing

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Stuart Sherman, MD, FACG

Sphincter of Oddi Dysfunction Causing IARP (9 series 1985-2010)

  • No. patients

Frequency SOD 1757 698 (40%)

Does Biliary Sphincterotomy Alone “Cure” Pancreatitis in SOD?

Therapy # Pts. F/U Asymptomatic Biliary ES 16 5 yr 44%

  • Sherman. GIE 1993;39:331A
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Stuart Sherman, MD, FACG

Pancreatic Sphincterotomy

ARP and Increased Pancreatic Sphincter Pressure: Need for Ablation of Both Biliary and Pancreatic Sphincters

Number Pts Therapy N Improved BD ES 18 5 (28%) BD ES + PD balloon 24 13 (54%) dilation BD ES + PD ES 27 22 (81%) p < .001

  • Guelrud. GI Endosc 1995;41:398A
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Stuart Sherman, MD, FACG

IARP – RCT of BDES vs. BDES + PDES for Pancreatic SOD (f/u 7 years)

Coté. Gastro 2012

p = 1

  • SOD is the most common cause of IARP

when detailed endoscopic evaluation performed

  • Sphincter of Oddi manometry is the gold

standard for diagnosing SOD

  • The best therapy awaits further study

– At present, the role of sphincter therapy remains unclear

Conclusions: IARP Due to SOD

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Stuart Sherman, MD, FACG

Pseudocysts

Pseudocyst

  • Localized collections of

pancreatic juice

  • Enclosed by a non-

epithelialized wall

  • Arise as consequence
  • f acute pancreatitis,

chronic pancreatitis, or pancreatic trauma*

  • Typically require  4

weeks to form

* Arch Surg 1993;128:586

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Stuart Sherman, MD, FACG

Pseudocysts: Endoscopic Therapy

  • Transpapillary
  • Transmural

– Cystogastrostomy – Cystoduodenostomy

  • Combined techniques
  • EUS and/or ERCP
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Stuart Sherman, MD, FACG

Pseudocyst Drainage Endoscopic Cystoenterostomy

  • Aim: Create a communication between

cyst cavity and gastric or duodenal lumen

  • Two prerequisites should be fulfilled

when doing video endoscopy

– Visible bulge – Cyst-to-lumen distance < 1 cm – EUS has expanded patient population eligible for endoscopic drainage

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Stuart Sherman, MD, FACG

Transmural Drainage

  • f Pseudocyst

Transmural Drainage

  • f Pseudocyst
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Stuart Sherman, MD, FACG

Pseudocyst Drainage

Potential Advantages of EUS-guided Drainage over “Blind Puncture”

  • Avoidance of intervening vascular structures

including varices

  • Assess degree of necrosis
  • Determine maturity of cyst wall
  • Easier sampling to rule out mucinous

neoplasm

  • Visible bulge not necessary for drainage
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Stuart Sherman, MD, FACG

RCT: EUS-Guided vs. Conventional Transmural Drainage of Pseudocysts

Outcome EUS (n=31) Conventional (n=29) P-val Technical Success 94% 72%* .039 Complications 7% 10% .67 Short-term resolution 97% 91% .57 Long-term resolution 89% 86% .70

  • Park. Endosc 2009;41:842.

*8 nonbulging cysts successfully treated by EUS on crossover

Endoscopic Therapy of Pseudocysts (15 Series, ERCP + EUS; 1985-2002)

No. pts. Initial Resolution Recur Complic Mortality 632 87% 15% 16% .3%

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Stuart Sherman, MD, FACG

RCT: Endoscopic vs. Surgical Cystgastrostomy for Pseudocyst Drainage

Outcome EUS + ERCP (n=20) Open Surgery (n=20) P-val Success 95% 100% .5 Recurrence (24 mos) 0% 5% .5 Complications 0% 10%` .24 Hospital stay 2d 6d <.001 Hospital costs ($) 7,011 15,052 .003

  • Varadarajulu. Gastro 2013;145:583.

Pancreatic Necrosis

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Stuart Sherman, MD, FACG

Acute Pancreatitis

  • Interstitial pancreatitis – 80%
  • Pancreas is inflamed but viable
  • Usually mild; focal and systemic complications rare
  • Secondary complications rare; infection is unusual
  • Mortality <2%
  • Necrotizing pancreatitis – 20%
  • Systemic toxicity is common
  • Infection may occur in 30% - 50%
  • Mortality, 10% in sterile necrosis; 30% in infected

necrosis

  • Distinction based on contrast-enhanced CT scan

48

pancreas fluid

Interstitial Pancreatitis

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Stuart Sherman, MD, FACG

49

fluid

stranding

necrosis

Necrotizing Pancreatitis

Organized Pancreatic Necrosis → Walled Off Pancreatic Necrosis

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Stuart Sherman, MD, FACG

Endoscopic Drainage

Outcome After Endoscopic Drainage

N Initial resolution Hosp Days Complic Recur “Cure” Acute Pcyst 31 74% 9 19% 9% 68% Chronic Pcyst 64 92% 3 17% 12% 81% Organized necrosis 43 72% 20 37% 29% 51%

  • Baron. GIE 2002;56:7
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Stuart Sherman, MD, FACG

RCT: Open Necrosectomy vs. Minimally Invasive “Step Up” Approach for Infected Pancreatic Necrosis (n=88)

Step Up Open Necrosectomy p value

Major complication or death 40% 69% .006 Multiorgan failure 12% 40% .002 Incisional hernias 7% 24% .03 Diabetes 16% 38% .02 Exocrine insufficiency 7% 33% .002 Healthcare utilization Lower <.001 Total cost $116,016 $131,979

NEJM 2010;362:1491.

Step up approach: Percutaneous or endoscopic drainage; video- assisted retroperitoneal debridement (VARD) if no improvement

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Stuart Sherman, MD, FACG

2013 – When is Endoscopic Treatment Indicated in Acute Recurrent Pancreatitis – Conclusions

Disorder No Yes

Gallstone pancreatitis √ Cholangitis; BD obst √ Pancreas divisum √ SOD ? Pseudocyst √ Pancreatic necrosis √