12 mohan ramchandani latest innovations in pancreatobiliary endoscopy 04 16

Recent Advances in management of Pancreatobiliary diseases Mohan Ramchandani Asian Institute of Gastroenterology Hyderabad, India... Photodynamic Therapy for CholangioCarcinomaAaron J Qu

Recent Advances in management of

Pancreatobiliary diseases

Mohan Ramchandani Asian Institute of Gastroenterology Hyderabad, India.

Techniques Technologies

Endoscopic Adjuvant Therapy

• Photodynamic therapy

• Radiofrequency ablation

• Brachytherapy

• Radioactive stents

Photodynamic Therapy for CholangioCarcinoma

Aaron J Quyn et al HPB 2009 Ortner et al gastroenterology 2003

Conclusion

PDT improves survival in Cholangiocarcinoma

n=20 n=19

Pre RFA Post RFA

D S Strand et al Gastrointestinal Endoscopy 2014

PDT vs RFA

Reddy D N et al Gastrointest Endosc 2014

Endotherapy of POBS

“Aggressive” approach

Successful Management of Benign Biliary Strictures With Fully

Covered Self-Expanding Metal Stents

Jacques Devière, D Nageshwar Reddy, Andreas Püspök, Thierry Ponchon, Marco, J Bruno, Michael J

Bourke, Horst Neuhaus, André Roy, Ferrán gonzález-huix,lladó, Alan N Barkun, Paul P Kortan, Claudio

Navarrete, Joyce Peetermans,Daniel Blero, Sundeep Lakhtakia, Werner Dolak, Vincent Lepilliez, Jan W

Poley,Andrea Tringali, Guido Costamagna

Gastroenterology 2014

Successful Management of Benign Biliary Strictures with

FCSEMS

Jacques Devière, Reddy D N et al Gastroenterology 2014

Plastic stents U SEMS PC SEMS Adjvant therapy +

SEMS

Malignant Biliary Stricture’s - 2015

Multiple

? Biodegradable

stents

Benign Biliary Stricture’s - 2015

Preoperative Billiary Drainage

High grade

obstruction

or complication

Low grade obstruction

Plastic vs SEMS Complication rate >7x Hospitalization >3x Time to complication <3x

Conclusion

Compelling evidence indicates that self-expanding metal, not plastic stents should be used for malignant biliary obstruction in patients undergoing

neoadjuvant therapy for pancreatic cancer

Megan A et al J Gastrointest Oncol 2012

Endotherapy of Chronic Pancreatitis

Chronic Calcific Pancreatitis - ESWL

Manu Tandan, DM, D Nageshwar Reddy, DM, Rupjyoti Talukdar, MD, K Vinod, MD, D Santosh, MD,

Sundeep Lakhtakia, DM, Rajesh Gupta, DM, Mohan J Ramchandani, DM, Rupa Banerjee, DM,

K Rakesh, DNB, G Varadaraj, DNB, G Venkat Rao, MS Hyderabad, India

Gastrointest Endosc 2013

Intraductal Lithotrispy

Mansour A et al Gastroenterology 2013

Pancreatic Strictures Fully Covered SEMS with Antimigration

AIGAIG

Single Operator Digital Cholangioscope

• No radiation

• Direct visualization

• Tissue access

• Directed Therapy

Abnormal epithelium

Biliary Confocal Endomicroscopy

Tumoral neo vessels

QuickTime™ and a decompressor are needed to see this picture.

Normal epithelium

Pancreatic Serous Cystadenoma

Intraductal Papillary Mucinous Neoplasm (IPMN)

Evolution of Pancreatic Necrosectomy

Endoscopic Necrosectomy

Seifert H et al Lancet 2000 Seewald S et al Gastrointest Endosc 2005

Cyst Wall Posterior Gastric Wall

Cyst Cavity

Short biflanged SEMS

Short biflanged SEMS as Port for

necrosectomy

Short biflanged SEMS EUS guided

Itoi T, Reddy DN et al J Hepatobiliary Pancreat Sci 2012

WOPN 4 Weeks after stent

Japanese multicenter study

BFMS Plastic stent

Conclusions: Plastic stents and BFMS were safe and effective for the

treatment of WON In particular, BFMS placement appeared to be

preferable for initial EUS-guided drainage and additional reintervention (e.g DEN) as it reduced the procedure time Prospective randomized

controlled trials are warranted

Mukai et al Endoscopy 2014

PTBD

Ampulla accessible ?

Yes

EUS-guided rendezvousstricture traversable?

access)

Upstream drainage(Direct transluminal

access)

Khashab M A et al Gastrointest Endosc 2013

EUS guided Transgastric Rendezvous

From Mike Levy, Mayo Clinic Rochester

EUS Biliary rendezvous: Extra-hepatic

Courtesy Jacques Deviere

Endoscopic transduodenal drainage of the gallbladder:

implications for endoluminal treatment of gallbladder disease

Todd H Baron et al NEJM 2015

Asian Institute of Gastroenterology