1. Endotherapy of
chronic pancreatitis
Dr Chirayu Chokshi

2. EUS –MRCP OR BOTH OF THEM?
SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC
PATIENT WITH WT LOSS
ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF
MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

3. DIAGNOSIS
ENDOSONOGRAPHY
HIGHLY
91-100%
SENSITIVE
EUS FNA :LOW RISK OF SEEDLING
POOR
SPECIFICITY OPERATOR DEPENDENT
WITHOUT NOT AVAILABLE
BX

4. EUS, MRCP OR BOTH ?
EUS
DETECTION OF DEBRIS IN COLLECTION
CHANGES OF EARLY CHRONIC/CHRONIC PANCREATITIS
RULE OUT PSEDOANEURYSM
WALL VESSELS AND SELECTION OF SITE
r/o mass in pancreas
Endo. Treatment for chr pancreatitis,timing,duration and type of inteVrention
Thai Nguyen-Tang,Jean Marc Dumonceau.
2010 Clinical Gastroenterology.

5. EUS, MRCP OR BOTH ?
MRCP
MPD ANATOMY ESP.DOMINANT DUCTAL STRICTURE
,MPD OBSTACLE
RUPTURE OF MPD
COMMUNICATION WITH COLLECTION
ERCP ?
IF MRCP NOT CONCLUSIVE/NOT DONE
BEFORE DRAINAGE OF COLLECTION THOUGH SOMETIMES
DIFFICULT
Endo. Treatment for chr pancreatitis,timing,duration and type of intevention
Thai Nguyen-Tang,Jean Marc Dumonceau.
2010 Clinical Gastroenterology.

6. EUS –MRCP OR BOTH OF THEM?
SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC
PATIENT WITH WT LOSS
ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF
MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

8. 2007

9. WHEN SURGERY
PEARLS:
1.Successful TRIAL OF ENDOSCOPIC TREATMENT BEFORE SURGERY
2.DILATED DUCTAL SYSTEM AND FAILED MEDIAL AND ENDOSCOPIC TREATMENT
3.CANCER SUSPICION
4.PSEUDOCYST NOT AMENABLE TO ENDOSCOPIC TREATMENT
CHRONIC PANCREATITIS:ASIA PACIFIC CONSENSUS REPORT:
J OF GASTRO AND HEPATO.2002:17.508-518
R TANDON,P GARG,NOBUHIRO SATO

10. Pain in chronic pancreatitis:
Surgical options: MPD
DILATED DUCT NON DILATED
FOCAL INFLAMM.MASS
RESECTION-
DISTAL PANCREATECTOMY
PRESENT ABSENT HEAD RESECTION
DRAINAGE
RESECTION +DRAINAGE

11. SURGERY : STANDARD ,TIME TESTED TREATMENT
VARIABLE
RESULTS OF SURGERY: PATIENT SELECTION
TYPE AND EXTENT OF SURGERY
VARIABLE F/UP
SPONT.PAIN RELIEF AFTER DZ BURNOUT
WHY ENDOSCOPIC TRAETMENT?
LESS INVASIVE
SHORT RESULTS COMPARABLE TO SX
PREDICTS OUTCOME AFTER SX
SX ALWAYS POSSIBLE AFTER FAILED
ENDOTHERAPY

12. BEST CANDIDATE FOR ENDOSCOPIC TREATMENT:
STRICTURE IN PANCREATIC HEAD WITH ‘UPSTREAM DILATATION’
Cremer deveiere.Stenting in CP:Results of long term fup of 76 pts.
ENDOSCOPy 1991:23:171-176

13. Plastic stents for MPD strictures:
AUTHOR YR NO STENT F/UP EARLY PAIN RELIEF SUST.RELIEF OPERATED %
Cremer 1991 75 10 37 94% na 15
Ponchon 1995 23 10 14 74% 52 15
Smits 1995 49 10 34 82% 82% 6
Binmoeller1995 93 5/7/10 58 74% 65% 26
Morgan 2003 25 5/7/8.5 na 65% na na
Vitale 2004 89 5/7/10 43 83% 68% 12
Eleftheriades ‘05 100 8.5/10 69 70% 62% 4%
Ishiara 2006 20 10 21 95% 90% na
Weber 2007 17 all 24 89% 83% na
Large pancreatic stents are commonly used
After definitive stent removal , 27-38% have pain relapse in 2.1-3.8 yrs
Pain relapse treated with stenting
Short term pain relief 70-94% Long term pain relief 52-82%

14. EUS –MRCP OR BOTH OF THEM?
SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC
PATIENT WITH WT LOSS
ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF
MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

15. ERCP FOR PAIN IN CHRONIC PANCREATITIS
PANCREATIC SPHINCTEROTOMY MINOR PAPILLA DRAINAGE IN P.DIVISIUM
RELIEF OF DUCTAL OBSTRUCTION
STRICTURE REMOVAL OF OBSTRUCTED
DILATATION DUCTAL STONES
BALLOON/BOUGIE/ ESWL/MECH.LITHO
STENTS
EUS GUIDED :PANCREATICOGASTROSTOMY
PANCREATICODUODENOSTOMY
COELIAC AXIS BLOCK

16. Endotherapy of pancreatic stones:
Large stones
Stone above stricture
Dormia
Baloon extarction
Mech litho.ESWL
Balloon sphincteroplasty of papilla

17. VIDEO COURTESY BY DR V RATHOD

18. MPD DRAINAGE SHOULD BE PLANNED EARLY IN COURSE
OF CALCIFYING CP
STONES 18%
STRICTURES 47%
STONE AND STRICTURE 32%
51% HAD NO PAIN IN 4.9 YRS
Duomoneauque jm,j deviere Endoscopic pancreatic drainage in chronic pancreatitis
associated with ductal stones.long term results.GIEndoscopy 1996:43:547-55
Binmoeller ,soehendra Endoscopic pancreatic drainage in CP and a dominant stricture .
ENDOSCOPY 1995:27;638-44
RoschT,Daniel,Huibregtse Endoscopic rx of CP:multicenter study of 1000 pts.
ENDOSCOPY 2000:34;765-71

19. Pancreatic stone management :
Small , 5mm non calcific stones can be removed with ERCP
J Deveriare .GIEndoscopy 1996:43:547-55
70-90% stones cannot be extracted without
pre ERCP fragmentation
Farnbacher ,Schoen schneider.Pancraetic stone ductal in chr pancreatitis.
Criteria for treatment intensity and success.GIEndoscopy 20012:56:501-6

20. for pain in calcifying CP
ESWL:
First line mx
COMPLETE PAIN RELIEF IN 62% VS 55%
after 2yrs
Costamagna et al Treatment for painful calcified chronic pancreatitis”ESWLv/s
endoscopic Rx:RCT
GUT2007:56:545-7
OharaTakeuchi et al Single application eswl is the first choice in CCP.AmJgastr 1996:91:1388-94

22. Take home message:
ESWL alone or ERCP combined should be done
early in course of painful CP
Delahaye,J Deveiere Long term clinical outcome in painful CP after endoscopic
pancreatic ductal drainage
Clininc gastr hepatology 2004:2:1096

23. EUS –MRCP OR BOTH OF THEM?
SURGERY OR ENDOTHERAPY IN 40 YR OLD ALCOHOLIC,DIABETIC
PATIENT WITH WT LOSS
ROLE OF ENDOTHERAPY FOR CHR PANCREATITIS IN PAIN RELIEF
MANAGEMENT OF NON COMMUNICATING PSEUDOCYST

24. DEFINITIONS OF PANCREATIC FLUID COLLECTION
CHRONIC PSEUDOCYST:
COLLECTION OF PANCREATIC JUICE ENCLOSED BY
WALL OF FIBROUS OR GRANULATION TISSUE DUE TO CHRONIC PANCREATITIS
INCIDENCE OF PSEUDOCYST AFTER AC PANCREATITIS 5-16%
CHR PANCREATITS 20-40%
BRADLEY EL A CLINICALLY BASED CLASSIFICATION SYSTEM FOR AC PANCREATITIS.SUMMARY
OF INTERNL SYMP ON AC PANCREATTIS 1992
ARCH SURG 1993:128:586-590
BARTHET M BUGALLO M MX OF CYSTS AND PSEUDOCYSTS COMPLICATING CHR PNCREATITIS,A RETRO STUDY 143 PTS.
GASTROENTEROLOGY CLINC BBIOL 1993: 17- 2770-276
ELLIOT PANCREATIC PSEUDOCYSTS SURG CLINIC OF N AMERICA 1975:55-339-362

25. CHRONIC PSEUDOCYSTS DUE TO ALCOHOL
64%
ALCOHOL RELATED PANCRETIC PSEUDOCYSTS 56%-78%
AETIOLOGY OF PANCREATITIS:
GALL STONE 6-36%
POST TRAUMATIC OR SURGICAL 3-8%
IDIOPATHIC 6-20%
SANFEY H JONES PSEUDOCYSTS OF PANCREAS ,A REVIEW OF 143 CASES AM SURG 1994:60:661-668
LAWSON LC FROMKES ERCP IN MX OF PANC PSEUDOCSTS AM J SURG 1985-:150:683-686USATOFF V OPERATIVE TREATMENT OF
PSEUDOPCYSTS IN CHRONIC PANCREATITIS BR J SURG 2000 :87-1494-1499
KOLARS JC PANCREATIC PSEUDOCYSTS ARCH SURG 1990 125:759-763

26. CT SCAN IS MANDATORY
FOR PLANNING
THERAPY OF PANCREATIC PSEUDOCYST
SENSITIVITY 82%-100%
SPECIFICITY 92-94%
OVERALL ACCURACY 88-94%
HAWES RH ENDOSCOPIC MANAGEMENT OF PSEUDOCYST
T.Rev Gastroenterolo Disord 2003 :3;135-141
LEE STALEY PANCREATIC IMAGING BY US/CT SCAN Radiological clinicof N A 1979:17:105-117

27. MX OPTIONS: ENDOSCOPIC RX
:
Create an alternative correct duct disruption
CYSTOENTERAL drainage route
TRANSMURAL DRAINAGE TRANSPAPILLARY DRAINAGE
GIE 2009 2004 1999.CURRENT TRENDS IN GASTROENTEROLOGY 2002

28. CT SCAN Prospective series of 50 pts :endoscopic drainage
possible in 98% pts and
collection dissapearence in 98% cases
with a f/up of 11 months
PORTAL HT NO PORTAL HT
NO DIGESTIVE BULGE DIGESTIVE BULGE
LARGE CYST >= 5 CM CYST <5 CMS
NO PD COMMUNICATION PD COMMUNICATION
EUS GUIDED PROCEDURE TRANSPAPILLARY DRAINAGE TRANSMURAL DRAINAGE
BARTHET etal Clinical usefullnesss of the a treatment algorithm f or pancreatic pseudocyst
G I ENDOSCOPY 2008:VOL 67;245-52

29. INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTS
COMPLICATED PANCREATIC PSEUDOCYSTS [1 CRITERION SUFFICENT]
COMPRESSION OF LARGE VESSELS[CLINICAL SYMTOMSOR
ON CT SCAN]
GASTRIC OR DUODENAL OBSTRUCTION
STENOSIS OF THE CBD
INFECTED PSEUDOCYST
H’GE INTO PSEUDO CYTS
PANCRETICOPLEURAL FISTULA

30. INDICATION S FOR THERAPEUTIC INTERVENTION OF PANCREATIC PSEUDOCYSTS
SYMTOMATIC PANCREATIC PSEUDOCYSTS
SATIETY
PAIN
N AUSEA VOMITING
UPPER G I BLEED
ASYMTOMATIC PANCREATIC PSEUDOCYST
DIAMETER MORE THAN 4 CMS AND EXTRAPANCREATIC COMLN IN PTS
WITH CHRONIC ALCOHOLIC PANCREATITIS
PSEUDOCYTS MORE THAN 5 CMS-UNCHANGED MORPHOLOGY FOR MORE THAN 6 WKS

31. PREREQUISITE FOR ENDOSCOPIC DRAINAGE
DISTANCE OF PSEUDOCYST TO THE GUT WALL LESS
THAN 1 CM
LOCATION OF TRANSMURAL APPROACH BASED ON MAXIMUM
BULGE OF THE
PSEUDOCYST TO THE ADJACENT WALL
Rossea e ,Pancreatic Pseudocyst in Chronic pancreatitis.endoscopic
and surgical treatment Dig surg 2003:20:397-406
Monkemuller ,kahl.Endoscopic therapy of chronic pancreatitis. Dig dz 2004:22:280-291
Smiths ME,RauwsTytgat .The efficacy of endoscopic treatment of pancreatic pseudocysts.
Gastrointestinal endoscopy 1995:42-202-207
Monkemuller KE Baron Morgan.Transmural Drainage of pancreatic fluid collection using
seldinger technique.Gastrointestinal Endoscopy 1998:48:195-200

32. 6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS

34. 6MTH CHILD WITH PSEUDO CYST AFTER AC.PANCREATITIS
Pseudocyst drainage by gastroscope

36. ENDOSCOPIC DRAINAGE :COMPLICATIONS
5-16%
MORE IN CASE OF NECROSIS
BLEEDING: 8-10%
-PSEUDOANEURYSM
- GASTRIC DUODENAL VESSEL RUPTURE
- ENLARGED COLLATERALS
- INFECTION:less than 5% in clear pseudocysts
Retroperitoneal perforation
Stent migration
Stent induced ductal changes
J GISURGERY 2008,PANCREAS 2008,GIE 2004

37. Take home message: endoscopic treatment only when
Single MPD stone
Single stricture in MPD
Single stone and stricture
Early Pancreas divisium
Pseudocyst with clear contents or minimal
debris

38. Endoscopic pancreatic necrosectomy:
Limited in its use in centres of expertise that deal with pancreatic
necrosis day in and out
Insufficient data to recommend a particular technique
Though included in 10-15 guidelines,,,level of evidence supporting
recommendationis
not included
WJS loveday BP 2009

39. Can is definitely not should !!!