A Clinical Update in Pancreaticobiliary ... - Einstein Health...Conventional methods of performing...

A Clinical Update in Pancreaticobiliary

EndoscopyMichael Rajala MD

Director of GI Endoscopy Einstein Healthcare Network

Disclosures:• No financial disclosures or COI.

Management of choledocholithiasis in patients with roux-en-y gastric bypass anatomy is more complicated than typical management (ERCP) due to post surgical anatomy

Laparoscopy-assisted ERCP (LA-ERCP)

Balloon-enteroscopyassisted ERCP

Conventional methods of performing ERCP in patients post roux-en-y:

Device-assisted ERCP (DAE)Failure rates of at least 30-40% at expert

centers

Laparoscopy-assisted (LAE)High success (100% versus 59% of DAE*)Increased adverse eventsConversion to open in 5-13%*Gastrointest Endosc. 2012 Apr;75(4):748-56

Gastrointest Endosc Vol 88 (3), Sept 2018, 486-494

SAGES

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Lumen apposing metal stent (LAMS) – allows for safe creation of fistula to drain pancreatic fluid collections

Pseudocyst drainage with LAMS

Gastrointest Endosc Vol 88 (3), Sept 2018, 486-494

EUS-directed transgastric ERCP (EDGE)-success of 90% or more-decreased hospital LOS-avoids surgery/associated adverse events

concerns:-no long term follow up-rates of G-G or J-G fistula unknown -potential on risk for weight gain unknown

DDW2019 – Presentation 1026, Thomas M Runge et al.

Multicenter retrospective study at 13 sites over 4 years

178 patientsend points:

Technical success (stent placement/completion ERCP)

Persistent fistula (>8weeks)Refractory fistula despite closure attempt

DDW2019 – Presentation 1026, Thomas M Runge et al.

Results:3 aborted due to misdeployment of LAMs3 failed initial ERCP, but successful on repeat

attempt175/178 ultimately successful

Closure attempt at LAMS removal49% none, or APC33% endoscopic suturing6% clips (OTSC or TTS)

DDW2019 – Presentation 1026, Thomas M Runge et al.

Adverse Events:

Persistent fistulas & effect on weight with fistula:

Affects on weight change were variable Closure of fistula successful when attempted (5/5 cases)No refractory fistula noted

TAKE HOME:

• Technical success of ERCP with EDGE is high

and comparable to ERCP in native anatomy

• SAFE with low risk of short-term and long term

complications

• Persistent fistulas are uncommon and can be

treated endoscopically

• Effect of persistent fistulas on weight is variable

but can occur

New management options for acute cholecystitis in

non-operative or high risk patients

Management of acute cholecystitis

Operative candidates Non-operative candidatesLaparoscopic Cholecystectomy Percutaneous CholecystostomyOpen Cholecystectomy Transpapillary Drainage

Transmural Drainage

Percutaneous Gallbladder Drainage

Gastrointestinal Endoscopy, Volume 89, Issue 2, Pages 289-298

Endoscopic Transpapillarydrainage

EUS-guided cholecystostomy

EUS-guided gallbladder drainage (EGBD) reduced adverse events compared to percutaneous cholecystectomy (PC) in patients suffering from acute cholecystitis that are high risk for surgery. A randomized controlled trial (DRAC)

Teoh AY et al Presentation 1025 DDW2019

AIM: Compare EGBD with PC as a definitive treatment, in high-risk patients suffering from acute cholecystitis in a randomized controlled trial.

Prospective multi-centered open labeled randomized controlled study involving 5 high-volume institutions• ≥ 18 years old admitted for acute calculous cholecystitis but

were unsuitable for early laparoscopic cholecystectomy due to poor premorbid conditions

• Primary outcome measurement: 1-year morbidity rate. • Secondary outcomes:

• technical and clinical success• unplanned readmissions • re-interventions and mortalities.

August 2014 to February 2018, 80 patients

Teoh AY et al Presentation 1025 DDW2019

Criteria for very-high risk-cholecystectomy:• Age >80• ASA grade 3 or above• Age-adjusted charlson score >5 and/or

Karnofsky score < 50• Surgeons and anesthesiologist jointly made

the decision

Teoh AY et al Presentation 1025 DDW2019

Exclusion: • Suspected gangrene or perforation of gallbladder• Previous drainage of gallbladder• Concomitant liver abscess or pancreatitis• Altered anatomy• Decompensated liver cirrhosis, portal HTN and/or

gastric varices• Coagulopathy• Pregnancy• Unwilling to undergo follow-up assessments Teoh AY et al

Presentation 1025 DDW2019

Follow up at 1 month:

Cystic duct patent

PC

Remove PC Long term PC

NOYES

All stones cleared

EGBG

Remove LAMS

Replace with 7Fr double pigtail stent

Teoh AY et al Presentation 1025 DDW2019

Reduced 1 year adverse events (25.6% versus 77.5% for PC) Reduced reinterventions at 30-days (2.6% versus 30%)

Teoh AY et al Presentation 1025 DDW2019

Reduced unplanned admissions (15.4% versus 50% for PC) Reduced 30-day adverse events (12.8% versus 47.5%)

Teoh AY et al Presentation 1025 DDW2019

Teoh AY et al Presentation 1025 DDW2019

Tube dislodgement in PC

Tube dislodgement and recurrent acute cholecystitisin PC

Conclusion:• At one year, EUS-GBD had reduced adverse

events, recurrence of cholecystitis, re-interventions and unplanned admissions

• In shorter term, it reduced 30-day adverse events, had lower post-procedural pain scores and analgesic requirements

• Findings support use of EUS-GBD as a definitive treatment for acute cholecystitis in those patients that can not receive cholecystectomy

EUS-Guided versus Percutaneous Gallbladder Drainage in Patients who are Unfit for Cholecystectomy: A Community Hospital Setting

Tu1129, DDW 2019Retrospective review of EUS-GBD verus PC nov 2016-201840 patients (30 PC and 10 EUS-GBD)Technical success in all groups (100%)Clinical success in EUS-GBD 100% versus 86.7% in PCNo immediate adverse eventsDelayed events:

EUS-GBD recurrent cholecystitis, 1 pain PC 7 pain, 5 tube dislodgement, 1 bleeding

Both EGBD and PC are safe and effective in community hospital setting

Outcomes of Endoscopic Gallbladder Drainage in Acute Cholecystitis: Transpapillary Approach versus Endoscopic Ultrasound-guided Transmural ApproachRetrospective, single center studyJanuary 2012 to October 2018Transpapillary(n=83) to EUS-guided (n=17)Technical success 78% transpapillary,

EUS-guided 100%6% recurrent cholecystitis in both

groups (n=1 for EGBD)EGBD provided higher technical success with similar clinical success rate and procedure related adverse events compared to transpapillary stenting

Nicha Teeratorn et al. Presentation 1029 DDW2019

Treatment for malignant gastric outlet obstruction (mechanical blockage of the stomach or proximal small bowel by tumor). What’s current and what’s new.Malignant gastric outlet obstruction:-Advanced and unresectable-Nausea, intractable vomiting, dehydration, abdominal pain and malnutrition-Mean life expectancy typically short, estimated mean survival of 7 to 20 weeks.

GIE. June 2019. Volume 17, Issue 7, Pages 1242–1244

Cons:Delayed oral intakeExtended hospital stay

Surgical management

Pros:Lower risk for recurrent

obstruction

Pros: EndoscopicReduced hospital stay

Cons:Subject to tumor ingrowth, tumor overgrowth, clogging by food, and (rarely) migration.

GIE 2010,71:490-499Endosc Int Open 2016;4E1158-W1170

Endoscopic management

Which is better?

Multiple conflicting studies

Bottom line:Healthier patients with a longer anticipated lifespan should undergo surgery, while more compromised patients with a shorter anticipated lifespan might be best treated via stents.

EUS-guided gastroenterostomy

What’s new?

GIE. June 2018. Volume 87, Issue 6, Supplement, Page AB46

68 EUS-GUIDED GASTROJEJUNOSTOMY WITH LUMEN APPOSING METAL STENT VERSUS ENTERAL STENT PLACEMENT FOR PALLIATION OF MALIGNANT GASTRIC OUTLET OBSTRUCTIONPhillip S. GexPhillip S. Ge, Joyce Y. YoungxJoyce Y. Young, William DongxWilliam Dong, Christopher C. ThompsonBrigham & Women's Hospital, Boston, MA

Higher clinical success with EUS-GJ (91.7%) versus enteral stent (69.1%)

GIE. June 2018. Volume 87, Issue 6, Supplement, Page AB46

Lower Stent failure requiring re-intervention in EUS-GJ (8% versus 31.6%)

GIE. June 2018. Volume 87, Issue 6, Supplement, Page AB46

Lower total adverse events in EUS-GJ(20.8% versus 40.2%)

When compared to enteral stent placement, EUS-GJ has higher rate of initial clinical success and lower rate of stent failure requiring repeat intervention.

EUS-GJ should be considered as a minimally invasive alternative for selected patients with malignant gastric outlet obstruction

GIE. June 2018. Volume 87, Issue 6, Supplement, Page AB46

GOO etiology (20 patients): peptic stricture, anastomotic stricture, duodenal hematoma, RAP, chronic pancreatitis and pancreatic pseudocyst

Retrospective design, small number of patients and lack of standardized

procedure

Summary:

• High technical success (95%)

• Low adverse event rate (5%)

• EUS-GE was able to prevent surgery in 85% of cases

• LAMS needed to stay in place for ~8.5 months to allow resolution of GOO

Eus-Guided Gastroenteric Anastomoses As A Bridge To Definitive Treatment In Benign Gastric Outlet Obstruction

Session 5170, #894, DDW 2019

Adverse events –Bleeding tx endoscopically (1 pt)5 pts with recurrent GOO with LAMS in place.

3 managed endoscopically, one converted to PEJ and PEG, one converted to surgical GE

Conclusions: EUS-guided gastroenterostomy is effective for benign GOOMajority of patients were effectively bridged to resolution of obstructionRate of conversion to surgical anastomosis was lowProspective clinical trials are needed

Eus-Guided Gastroenteric Anastomoses As A Bridge To Definitive Treatment In Benign Gastric Outlet Obstruction

Session 5170, #894, DDW 2019

Summary:

New EUS-guided approaches utilizing LAMS are proving to be effective and safe therapies, or adjuncts to therapy, for the management of choledocholithiasis in patients with post surgical anatomy, acute cholecystitis in high risk patients and malignant gastric outlet obstruction in select patients as well as indications for pancreatic fluid collections. More indications will surely follow

Thank you