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

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 of post-ERCP pancreatitis

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

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

Stuart Sherman, MD, FACG Emergent ERCP (< 24 hr) vs Conventional Rx For Gallstone Pancreatitis Group / Overall Biliary Treatment N Complications Sepsis Death Mild – 35 17% 11% 0% Conventional Mild – 34 18% 0% 0% ERCP/ES Severe – 28 54% ** 29% 18%* Conventional Severe – 30 13% 0% 3% ERCP/ES *p=0.07 (vs conventional); **p=0.003 Fan. NEJM 1993;328:228 Acute Gallstone Pancreatitis: Endoscopic Rx • 238 gallstone pancreatitis patients randomized within 72 hours of symptom onset 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.

Stuart Sherman, MD, FACG ERCP vs Conventional Rx For Acute Gallstone Pancreatitis Treatment Group Conservative ERCP/ES Complication (n=112) (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 Conclusions 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 of 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)

Stuart Sherman, MD, FACG Pancreas Divisum Pancreas Divisum • Most common congenital variant of PD anatomy • Occurs when dorsal and ventral ducts fail to fuse • With duct nonunion, the major portion of the exocrine juice drains into the duodenum via the dorsal duct and minor papilla • Common cause of unexplained recurrent pancreatitis

Stuart Sherman, MD, FACG Pancreas Divisum Minor Papilla

Stuart Sherman, MD, FACG Pancreas Divisum: Endoscopic Therapy • Aim to alleviate the outflow obstruction • Methods: dilation, ES, stenting Dorsal Duct Stent

Stuart Sherman, MD, FACG Minor Papilla ES Pancreas Divisum

Stuart Sherman, MD, FACG Minor Papilla Rx for Pancreas Divisum and ARP 12 studies 1986-2009 Follow-up No. pts. Improved (mos) 241 30 76% Pancreas Divisum and ARP: Results for Minor Papilla Stenting F/U Number Therapy (mo) Hosp. ER w/panc. Improved Stent 29 0 0 1 9 (90%) (n=10) Control 32 5* 2 7* 1 (11%)* (n=9) P<.05; Lans. GI Endosc 1992;38:430

Stuart Sherman, MD, FACG Conclusion: ARP Due to Pancreas Divisum • 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 Sphincter of Oddi Dysfunction

Stuart Sherman, MD, FACG Sphincter of Oddi Triple Lumen Catheter

Stuart Sherman, MD, FACG Sphincter of Oddi Manometry SO Manometry Tracing

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

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%) p < .001 dilation BD ES + PD ES 27 22 (81%) Guelrud. GI Endosc 1995;41:398A

Stuart Sherman, MD, FACG IARP – RCT of BDES vs. BDES + PDES for Pancreatic SOD (f/u 7 years) p = 1 Coté. Gastro 2012 Conclusions: IARP Due to SOD • 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

Stuart Sherman, MD, FACG Pseudocysts Pseudocyst • Localized collections of pancreatic juice • Enclosed by a non- epithelialized wall • Arise as consequence of acute pancreatitis, chronic pancreatitis, or pancreatic trauma* • Typically require  4 weeks to form * Arch Surg 1993;128:586

Stuart Sherman, MD, FACG Pseudocysts: Endoscopic Therapy • Transpapillary • Transmural – Cystogastrostomy – Cystoduodenostomy • Combined techniques • EUS and/or ERCP

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

Stuart Sherman, MD, FACG Transmural Drainage of Pseudocyst Transmural Drainage of Pseudocyst

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

Stuart Sherman, MD, FACG RCT: EUS-Guided vs. Conventional Transmural Drainage of Pseudocysts EUS Conventional Outcome P-val (n=31) (n=29) 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. Initial Recur Complic Mortality pts. Resolution 632 87% 15% 16% .3%

Stuart Sherman, MD, FACG RCT: Endoscopic vs. Surgical Cystgastrostomy for Pseudocyst Drainage EUS + ERCP Open Surgery Outcome P-val (n=20) (n=20) 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

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 Interstitial Pancreatitis pancreas fluid 48

Stuart Sherman, MD, FACG Necrotizing Pancreatitis fluid stranding necrosis 49 Organized Pancreatic Necrosis → Walled Off Pancreatic Necrosis

Stuart Sherman, MD, FACG Endoscopic Drainage Outcome After Endoscopic Drainage Complic Recur “Cure” Initial Hosp N resolution Days Acute 31 74% 9 19% 9% 68% Pcyst Chronic 64 92% 3 17% 12% 81% Pcyst Organized 43 72% 20 37% 29% 51% necrosis Baron. GIE 2002;56:7

Stuart Sherman, MD, FACG RCT: Open Necrosectomy vs. Minimally Invasive “Step Up” Approach for Infected Pancreatic Necrosis (n=88) Step up approach: Percutaneous or endoscopic drainage; video- assisted retroperitoneal debridement (VARD) if no improvement Open p Step Up Necrosectomy 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.