9/16/2017

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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

9/16/2017

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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 !!!???)