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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