new horizons in therapeutic endoscopy -...
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New Horizons in Therapeutic Endoscopy
Prof. Rama P.Venu MD, FACP, FACG, AGAF, FASGE,
Dip. American Board of Internal Medicine
HOD, Gastroenterology, AIMS, Kochi
New Horizons in Therapeutic Endoscopy
• Therapeutic ERCP• EUS and Endotherapy• EUS assisted ERCP• Per oral Endoscopic Myotomy
New Horizons in Therapeutic Endoscopy
• Diagnostic ERCP – No role • MRCP is preferred for diagnosis
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New Horizons in Therapeutic Endoscopy
• A 67 yr old female presented with abdominal pain, jaundice and weight loss.
• Labs :– Bili : 4 mg/Dl– ALP : 340 IU– AST/ALT : 100/112
MRCP – Diagnosis and staging
Case history
61 y/F, otherwise healthy presented with increased LFT noted for life insurance exam
Physical Examination : Mild scleral icterus
P/A : No mass
Labs: Total bilirubin: 3 mg/dl,
• Direct Bil: 9.4mg/dl, SGOT/SGPT: 100/112, ALP: 300
MRCP
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MRCP – Useful in staging CCA
New Horizons in Therapeutic Endoscopy
Therapeutic ERCP • Endoscopic Spincterotomy• Endoprosthesis• Cholangioscopy
Endoscopic Sphincterotomy
Techniques and Indications
Technique• Enlarge the bile duct opening through systematic
incision of the smooth muscle fibers constituting the sphincter of OddiIndications
• Management of Choledocholithiasis• Enlarge the papillary passage for endoprosthesis,
biliary dialators, lithotripstor, cytology device, cholangioscopy
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New Horizons in Therapeutic Endoscopy
Choledocholithiasis - Management
Defiant stones • Sphincteroplasty
Technique : Balloon Dilatation: 15 – 20 mm Stone extraction
• Laser lithotripsy
Through Cholangioscopy
New Horizons in Therapeutic Endoscopy
Cholangiocarcinoma
• Tissue acquisition • Case history : 68 yr old male with
– Jaundice– Fatigue– Pruritus– Lab
• Bili : 18 mg/dL• ALP : 610 IU• AST/ALT : 136/140 mg/dL• CT : IHBRD• ERCP, Endocsopic sphincterotomy, brush cytology
Findings : Cellular AtypiaProblem : Poor yield of brush cytology
New Horizons in Therapeutic Endoscopy
Cholangioscopy – Biopsy under direct vision
• Better tissue acquisition • Staging • Other application
– Guide wire manipulation
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EUS – Endotherapy for pancreatic disorders
• Necrosectomy• Pseudocyst drainage• Fiduciary placement • Radiofrequency ablation for pancreatic
tumours
EUS Endotherapy for Biliary disorders
• Biliary drainage in malignant bile duct obstruction
EUS Endotherapy in conjunction with ERCP
• Pancreatic disorders – Stent placement – Rendezvous technique– Pancreatic ascites
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EUS Endotherapy in conjunction with ERCP
• Biliary Disorders – Transjejunal– ERCP in patients with Roux-en Y hepatico
jejunostomy through EUS guided bypass anastomosis with lumen apposing metal stent
New Horizons in Therapeutic Endoscopy
POEM
• Indications • Techniques • Results • Complications
POEM
• Haruhiro Inoue 2008• Submucosal tunnel created Muscle cut
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POEM- Steps
• Mucosal incision
• Creation of Submucosal tunnel
• Endoscopic myotomy
• Closure of mucosal entry
POEM- Steps
POEM- Complications• Most common- related to insufflation- capno thorax, capno
mediastinum, capno peritoneum– Decompression needed only in 8% with capno peritoneum and
2.7% with capno thorax
• Mediastinitis
• Bleeding-– Procedural-No reported cases that could not be controlled
endoscopically-– Post procedural in 1%- managed conservatively and
endoscopically- ( Sengstaken- Blakemore tube was placed !!!???)