Powerpoint Vorlage KSSG · Chronische Pankreatitis Diagnostics by Rx 21.02.2011 Diffuse...

Chronische Pankreatitis

Vielen Dank für die Unterstützung!


Diagnostik und Interventionen bei

der chronischen Pankreatitis (CP)

Stellenwert der ERCP

Prof. Dr. Jan Borovicka

Klinik für Gastroenterologie/Hepatologie

Kantonsspital St. Gallen


Beyond endoscopy...

Role of CP in Switzerland ? Incidence of pancreatic cancer in CP Mechanisms of pancreatic function ? Correlation of ERCP and pancreatic function? ESGE Guidelines for MPD and biliary stricture


Diagnostics by Rx

21.02.2011

Diffuse calcifications are specific, not sensitive Alcoholic, tropical and hereditary pancreatitis


Lowenfels AB; N Engl J Med 1993.

http://www.google.ch/url?sa=i&rct=j&q=&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwjI-L3uv7DPAhXL0RoKHf7WBv0QjRwIBw&url=https%3A%2F%2Fde.wikipedia.org%2Fwiki%2FSchweiz&psig=AFQjCNFT8FKlmsI8Keitnc1PeDU7BZq1Eg&ust=1475098391055579


Cumulative incidence of pancreatic cancer

Lowenfels AB; N Engl J Med 1993.


Physiology of pancreatic function / secretion


Physiology of pancreatic function

Model of CP: Orlistat (Xenical®)

J. Borovicka; Gut 2000;46:774–781


J. Borovicka; Gut 2000;46:774–781

Physiology of pancreatic function

Model of CP: Orlistat (Xenical®)


Funktion = Bildgebung im ERCP/MRCP?


ERCP (Goldstandard) 5% Komplikationen, Sensitivität 85-95%, Spezifität 80-100%

29.09.2016


Correlation between the Cambridge score

and the peak lipase concentration

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:1432–1436


Correlation between the Cambridge score and

the peak lipase concentration

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:1432–1436

ERCP has modest sensitivity and high specificity

MPD abnormal !


Endoscopic therapy


The ESGE recommends endoscopic therapy as the first-line therapy for painful uncomplicated chronic pancreatitis.

The clinical response should be evaluated at 6–8 weeks; if it appears unsatisfactory, MDT: surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy

Dumonceau J-M et al. ESGE Guideline for endoscopic treatment of chronic pancreatitis… Endoscopy 2012; 44: 784–796

ESGE Clinical Guidelines: MPD


Factors independently associated with long-term (≥2 years) pain relief following endoscopic therapy of chronic pancreatitis include: Location of obstructive calcifications in the pancr. head Short disease duration Low frequency of pain attacks before endoscopic therapy Complete MPD stone clearance Absence of MPD stricture at initial endoscopic therapy Discontinuation of alcohol and tobacco during follow- up




Successful stone fragmentation following ESWL has been defined as: Stones broken into fragments ≤2 or 3mm Demonstration of a decreased stone density at X-ray increased stone surface Heterogeneity of the stone which may fill the MPD and

adjacent side branches




Endoscopic attempts at MPD stone extraction without ESWL: low success and high complication rate even with pancreatic stones<10mm in diameter ESWL consistently provides stone fragmentation in 90% of patients facilitates endoscopic extraction Spontaneous elimination of stone fragments resulting from

ESWL occurs in approximately 80% ESWL alone is more cost-effective than ESWL systematically

combined with ERCP.




ESWL


Spyglass® and EHL

Ito K et al. BioMed Research International 2014


Uncomplicated painful chronic pancreatitis and radiopaque stones ≥5mm obstructing the MPD: ESWL as a first step, immediately followed by endoscopic extraction of stone fragments. Endoscopic attempts to extract radiopaque MPD stones

without prior stone fragmentation should be considered only for stones<5mm, preferably low in number, and located in the head or body of the pancreas.

Intraductal lithotripsy should be attempted only after failure of ESWL

Dumonceau Jof chronic pancreatitis… Endoscopy 2012; 44: 784–796



Management of main pancreatic duct strictures Pancreatic stenting is technically successful in 85–98% of

attempted cases; it is immediately followed by pain relief in 65–95% of patients Follow-up (14–58 months), pain relief in 32%–68% of patients Single 10-Fr plastic stent, with stent exchange planned within

1 year even in asymptomatic patients to prevent complications related to pancreatic stent occlusion

Dumonceau Jof chronic pancreatitis… Endoscopy 2012; 44: 784–796



Novel fully covered self-expandable metal stent. Niti-S Biliary S-Type Stent Long Suture 6 mm and the delivery system is 8Fr.

Ogura T et al. her Adv Gastroenterol 2016


a. Stricture in the pancreatic head. b. Metal stent placement c. Stricture removed.

Chronische Pankreatitis 31

187 patients with benign biliary strictures received FCSEMS (WallFlex)

Diameters of 8 or 10 mm and in lengths of 60 or 80 mm. Position of the stent: 5–10 mm visible outside the papilla Stent removal after 10–12 months in CP and CCY patients 4–6 months in OLT patients. Allow resolution after shorter indwell while eliminating the risk of late complications in these immunosuppressed

patients.

CP and Benign Biliary Strictures

With Fully Covered Self-Expanding Metal Stents

Devière et al. Gastroenterology 2014


Successful Management of Benign Biliary

Strictures With Fully Covered Self-Expanding Metal Stents

32

Stents could be removed endoscopically with rat-tooth forceps in 85% of patients and with snares in 12%. A stent-in-stent technique was required in only 3 patients, 2 of

whom had experienced proximal stent migration. Ultimately, endoscopic removal was accomplished in all cases

attempted. Overall, stricture resolution rate was 76.3% 79.7% for CP patients; 68.3% for OLT; 72.2 % for CCY

Devière et al.Gastroenterology 2014


Successful Management of Benign Biliary Strictures

With Fully Covered Self-Expanding Metal Stents

33

Stricture resolution after FCSEMS placement. Devière et al Gastroenterology 2014




Fully Covered Self-Expanding Metal Stents

34

Temporal pattern

of FCSEMS

migration Devière et al Gastroenterology 2014

Patients

without

migration

(%)




Fully Covered Self-Expanding Metal Stents

35

Patients with Stent- or Removal-Related Serious Adverse Events Devière et al Gastroenterology 2014



CP-Patient A before B during C after FCSEMS



CP-Patient A before B after FCSEMS C after removal D after multiple plastic stents

Ogura T et al. Ther Adv Gastroenterol 2016


cSEMS (fully covered WallFlex, Boston Scientific) of sufficient length to traverse the stricture and the papilla; 8/10 mm

JAMA. 2016;315(12):1250-1257

http://www.musc.edu/


Biliary stenting: ESGE Guidelines 2012

In patients with benign CBD strictures, we recommend temporary placement of multiple plastic stents The insertion of uncovered biliary SEMSs is strongly discouraged

Covered SEMSs are a promising alternative for selected benign CBD strictures. Because of the risk of fatal septic complications, a recall system should be set

up for the care of patients who do not present for ERCP at scheduled dates

Dumonceau J-M et al. ESGE Clinical Guideline for biliary stenting… Endoscopy 2012; 44: 277–292


Cancer incidence is significantly elevated in CP Pancreatic function is normal in early CP Endoscopic therapy first, Surgery second ESWL first, combined ESWL and ERCP second Spyglass and EHL third Stenting: FCSEMS

Summary


Danke für Ihre Aufmerksamkeit !


Biliary stenting: ESGE Guidelines 2012

Dumonceau J-M et al. ESGE Clinical Guideline for biliary stenting… Endoscopy 2012; 44: 277–292


Aetiologie der CP: TIGAR-O

Etemad B. Gastroenterology 2001

Toxic-Metabolic Alkohol, Tabak, Hyperkalzämie, Hyperlipidämie, Chronische NI

Idiopathic Early/late onset, tropische Pankreatitis, whs. genetisch

Genetic Autosomal dominant (PRSS1), autosomal rezessiv (CFTR, SPINK1)

Autoimmune Autoimmune Pankreatitis

Recurrent and Severe Acute Pancreatitis Postnekrotisch, vaskulär, postaktinisch

Obstructive SOD, maligne, posttraumatisch, Zysten, Pankreas divisum


44

Ätiologie der CP: Verteilung der assoziierten Faktoren

CP: chronische Pankreatitis Frulloni L et al. Dig Liver Dis 41(4), 311-317 (2009)

n=893

27%

17%

9%

6%

4%

4%

Obstruktion

Idiopathisch

Alkohol und Obstruktion

Zystische Dystrophie der Duodenalwand / Rinnenpankreatitis

Autoimmun

Vererbbar / Genetisch


29.09.2016 Referent

CT: chronische Pankreatitis

Powerpoint Vorlage KSSG · Chronische Pankreatitis Diagnostics by Rx 21.02.2011 Diffuse...

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