Bile duct system / Papilla of vater

Standards and innovations

Brigitte SchumacherEVK Düsseldorf

Germany

Bile duct system / Papilla of vater Standards and innovations

diagnostic – why ?

Diagnosis of biliary strictures

ERCP and tissue diagnosis

Diagnosis of biliary strictures

Sensitivity of tissue samplingby ERCP for pancreatic cancer : combined data

41 42

51

68

0

10

20

30

40

50

60

70

Sensitivity %

brush fine needle biopsy combinationasp

Ponchon et al Gastrointest Endosc 1995 Howell et al Gastrointest Endosc 1996 , Jailwala et al Gastrointest Endosc 2000

Peroral cholangioscopy in PSC

Sens. Spec. PPV NPV

ERC 66% 51% 29% 84%

POCS 92% 93%* 79%* 97%

Tischendorf JJW, Endoscopy 2006

ERC vs cholangioscopy (n=53)

* P < 0,001

Diagnosis of biliary strictures

SpyGlass Direct Visualisation System

SpyScope™ Access & Delivery Catheter

• 4 Lumens

• 10 FR

• 1.2 mm Accessory Channel

• Four Direction Steering Capability

• Independent Irrigation Channel

• Single Use

SpyGlass Direct Visualisation System

SpyGlass Fiber Optic Probe

• 0.81mm outside diameter with 70° field of view

• Multi-use: Up to 20 high level disinfection cycles or 20 sterilization cycles per probe

• 365cm overall length

• One image bundle surrounded by light fibers

Diagnosis of biliary strictures

unclear stenosis in PSC

Diagnosis of biliary strictures

Spy Glass dataBiopsy of indeterminate biliary strictures multicenter registry

N = 60Indication for Spy Glass

Indeterminate strictures in non PSC 62 %

Dominant PSC – strictures 14 %

Non – diagnostic prior tissue sampling 10 %

Indeterminate filling defects 7 %

Other 7 %

Adequate tissue amount in 87 % Sensitivity 78 % Specificity 100 %PPV 100 % NPV 60 %

Pleskow et al DDW 2008

NBI

Peroral cholangioscopic diagnosis

Itoi et al Gastrointest Endosc 2007

N = 12 N = 7 bile duct cancerN = 5 benign strictures

NBI was equal or better than white-light Endoscopy in identifyingboth surface structure and mucosal vessels.

IDUS

Prospective study : accuracy of tumor staging by IDUS and

EUS in patients with ampullary neoplasm

N = 40

Itoi et al Gastrointest Endosc 2007

diag.accuracy EUS IDUSAdenoma and

pT162 % 86 %

pT2 45 % 64 %

pT3-4 88 % 75 %

overall accuracy

63 % 78 %

PSC

Complications after ERCP in patients with PSC

30 pat. with PSC comparing 45 pat. with no PSC

Complicationrate PSC non PSCin urgent 29.2 % 6.6 %

elective 7 % 0 %

overall 12.9 % 8,6 %

P<0.001

n.s.

n.s.

Etzel et al Gastrointest Endosc 2008

PSC

Standard treatment

Ponsioen et al Am J Gastroenterol 1999Stiehl et al J Hepatol 2002Bjornsson et al Am J Gastroenterol 2004

therapeutic ERC in pat. with dominant stricture,balloon dilation over a guidewire,

10 Fr stent across the stricture for 2-3 weeks

procedures should cover with prophylactic antibiotics

UDCA 20 – 25 mg/kg per day

Biliary sphincterotomy

Biliary sphincterotomy

EST plus large balloon dilation vs EST for removal of bile duct stones

Heo et al Gastrointest Endosc 2007

prospective randomized study

EST plus LBDN = 100

EST aloneN = 100

overall stone clearance

97 % 98 %

stone size 16 mm 15 mm

pancreatitis 4 % 4 %

bleeding 0 % 2 %

perforation 0 % 0 %

no significant difference

Stents

Metal vs. Plastic stents :palliation of malignant distal common bile duct obstruction

Autor stent ( n)metal plastic

median patency (mo)metal plastic

cost savingswith metal

DavidsLancet 1992

49 56 9,1 4,2 28%

KnyrimEndoscopy

1993

27 28 11 6 33%

PratGastrointest Endosc 1998

34 33 4,8 3,2 16%

KaassisGastrointest Endosc 2003

59 59 12 5,5 28%

Stents

randomized study : covered vs uncovered Diamondstent

covered uncoveredpat. 57 55

early stent obstruction

0 4

acute cholecystitis 4,8% 0 %

stent patency

3 mo. 100% 81%

6 mo. 91% 68%

12 mo. 74% 55%

tumor ingrowth 0% 29%

Isayama et al GUT 2004

Stents

randomized study : covered vs uncovered Wallstent

Yoon et al Gastrointest Endosc 2006

covered uncovered

pat. 36 41

survival (d) 392 + 60 308 + 42

stent patency (d) 245 + 48 202 + 29

cholecystitis 1 0

migration 2 1

no significant

difference

Stents

covered metal vs plastic stents for malignant common bileduct stenosis : a prospective, randomized, controlled trail

metall plastic

patency rate 3,6 mo 1,8 mo

stent – failure 8 22

survival more than 10 mo. without stent failure 8 3

C. Soderlund et al Gastrointest Endosc 2006 ;63:986-95

Klatskin tumor

Determining resectability

potential resectability should be determined before considering ERCP

► MRCP ; CT

► suitability of patient ( age , comorbidity )

► consultion of a hepatobiliary surgeon

Klatskin tumor

Principles of drainage

to relieve jaundice , only a minority of liver (25 %) needs to bedrained problems arise from infection of undrained segments

plastic stents :

► poor outcomes► unilateral drainage causes infection

► bilateral stents are difficult to place and often migrate► high complication rates ( 27 % - 63 % )

uncovered metal stents are superior to plastic for hilar tumors

Diagnosis and management of biliary strictures

*

Rotatable papillotome „Haber ramp“ and second guidewire

Klatskin tumor

bilateral metal stenting

Klatskin tumor

*

Klatskin tumor

*

Management of hilar strictures

*

suspected malignant jaundice

MRCP ; CT

Bismuth I , II , III Bismuth IVgood general health

Surgical resection unresectable ERCP ( metalstents)

unsuccessful

percutaneous approach