بسمبسماللهاللهالرحمنالرحمنالرحيالرحيمم

Change to ideal GIT center with minimal invasive technique

Aswad Alobeidy

ChangesChanges Liver biopsy to Fibroscan.Common bile duct exploration Vs

Spyglass.FNA with multiple sampl. to immediate

histopathology.Pancreatic pseudocyst surgery Vs

Endoscopic necrosectomy.Necrotizing Pancreatitis surgery Vs

Percutaneous necrosectomy.

Needs to changeNeeds to change

Low morbidity and complications.Short hospitalization.Minimum coast.Rapid diagnosis and intervention.Better outcome and prognosis.

StakeholdersStakeholderspo

wer

pow

er

Interest

4 Surgeon

2 PB physician

PB Radiologist

Interventional radiologists

Intensivists

Pathologist

Patients

Population

MOH

Some doctors

Nurses

FibroscanFibroscan A painless alternative to liver biopsy for

evaluating the stage of liver fibrosis A mechanical pulse is generated at the skin

surface, which is propagated through the liver. The velocity of the wave is measured by ultrasound.

The velocity is directly correlated to the stiffness of the liver, which in turn reflects the degree of fibrosis

metabolic syndrome and non-alcoholic fatty liver disease, chronic viral hepatitis and excess alcohol intake.

can monitor the progression, regression of liver disease and the success of treatments or lifestyle modification.

FibroscanFibroscan

FibroTest and FibroScan have excellent utility for the identification of HCV-related cirrhosis, but lesser accuracy for earlier stages. Refinements are necessary before these tests can replace liver biopsy (1)

in patients with chronic HCV hepatitis, liver stiffness measurement could be used for the decision of therapy, in most patients, avoiding LB. (2)

1. Am J Gastroenterol. 2007 Nov;102(11):2589-600. Epub 2007 Sep 10 2. Sporea I ,et al,World J Gastroenterol 2008; 14(42): 6513-6517.

SpyglassSpyglass

Visualise biliary system.Biopsy taken.Electro hydraulic or Laser

lithotripsy of difficult CBD stones

Procedure started at 16th June 2008

SpyGlass™ Direct Visualisation SystemSpyScope™ 10Fr Access

& Delivery Catheter

SpyBite ™ Biopsy Forceps

SpyGlass ™ Fiber Optic Probe

Monitor

Camera

Light Source

Pump

Cart

3-joint Arm

Isolation Transformer

ERBE Irrigation

Pump

ConclusionConclusion

Spyglass offers a potentially cost effective way to More accurately diagnose undetermined biliary

strictures by maintaining high sensitivity and a high NPV. The combination and appropriate sequencing of CT, EUS, ERCP and Spyglass should improve the management of biliary strictures.

Non operative management of large CBD stones that have failed conventional lithotripsy.

FNA with multiple sampl. to FNA with multiple sampl. to immediate histopathologyimmediate histopathology

Newly developed technique like FFB.The aim is to decrease the number of the

sampling.Immediate diagnosis and rapid

intervention Short procedure time.Coast effective.

Rationale for minimally invasive Rationale for minimally invasive necrosectomynecrosectomy

Definitive procedure - in patients with co-morbidity, Definitive procedure - in patients with co-morbidity, e.g. high BMI, advanced age, multiple organ failure e.g. high BMI, advanced age, multiple organ failure

Bridging procedure - to improve the patient’s Bridging procedure - to improve the patient’s condition and postpone the open procedure until condition and postpone the open procedure until resolution of organ failureresolution of organ failure

Open necrosectomy is associated with high mortality and morbidity

Infected necrosis is often walled off and applied to posterior wall of stomach

Percutaneous access may not always be possible particularly in necrosis of the head

Minimal access techniquesMinimal access techniques

Percutaneous necrosectomyPercutaneous necrosectomy

Laparoscopic necrosectomyLaparoscopic necrosectomy

Endoscopic necrosectomyEndoscopic necrosectomy

Steps in endoscopic Steps in endoscopic necrosectomynecrosectomy

EUS guided puncture to access the cavity– Majority of procedures performed entirely

with therapeutic linear scope– Currently use Cystotome ( Wilson-Cook)

Dilatation of opening over a wireRemoval of solid and liquid materialStents to keep cavity openNasocavity irrigation if necessaryCavity endoscopy sometimes possible

Endoscopic necrosectomy for Infected Endoscopic necrosectomy for Infected NecrosisNecrosis

May 2002-Oct 2004

Attempted on 13 patients with walled off necrosis via trans gastric approach. 11(84%) positive bacteriology

Patients identified on the basis of clinical/CT criteria

All patients had EUS prior to drainage, in the majority the entire initial procedure performed with echoendoscope

Nasocavity drainage if deemed necessary

2 patients had general anaesthesia (on 3 occasions)

• Charnley R et al. Endoscopy 2006 Sept; 38(9):925-8

RiskRisk

High coast e.g Fibroscan Not useful in all patientsProlonged procedure initiallyGood trainingComplications e.g endoscopic

necrosectomy

ConclusionConclusion Extensive necrosis can be successfully treated with a

minimal access technique or combination of techniques Endoscopic necrosectomy can be effective even in the

presence of infection Multidisciplinary team input is vital Labour intensive pastime: Input required for 1 case

– Surgeon - Percutaneous necrosectomy (4)– Gastroenterologist - EUS (1) /ERCP (1) / OGD (2)– Intensivist - 54 days– Microbiologist - 8 pathogens / 11 sites / 9 therapies– Radiologist - CT (7), CT drain (2), USS (6), Angiography

(3)– Ward staff - 64 days