powerpoint vorlage kssg · chronische pankreatitis diagnostics by rx 21.02.2011 diffuse...
TRANSCRIPT
Chronische Pankreatitis
Vielen Dank für die Unterstützung!
Chronische Pankreatitis
Diagnostik und Interventionen bei
der chronischen Pankreatitis (CP)
Stellenwert der ERCP
Prof. Dr. Jan Borovicka
Klinik für Gastroenterologie/Hepatologie
Kantonsspital St. Gallen
Chronische Pankreatitis
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
Chronische Pankreatitis
Chronische Pankreatitis
Diagnostics by Rx
21.02.2011
Diffuse calcifications are specific, not sensitive Alcoholic, tropical and hereditary pancreatitis
Chronische Pankreatitis
Lowenfels AB; N Engl J Med 1993.
Chronische Pankreatitis
Lowenfels AB; N Engl J Med 1993.
Chronische Pankreatitis
Cumulative incidence of pancreatic cancer
Lowenfels AB; N Engl J Med 1993.
Chronische Pankreatitis
Physiology of pancreatic function / secretion
Chronische Pankreatitis
Physiology of pancreatic function / secretion
Chronische Pankreatitis
Physiology of pancreatic function
Model of CP: Orlistat (Xenical®)
J. Borovicka; Gut 2000;46:774–781
Chronische Pankreatitis
J. Borovicka; Gut 2000;46:774–781
Physiology of pancreatic function
Model of CP: Orlistat (Xenical®)
Chronische Pankreatitis
J. Borovicka; Gut 2000;46:774–781
Physiology of pancreatic function
Model of CP: Orlistat (Xenical®)
Chronische Pankreatitis
Funktion = Bildgebung im ERCP/MRCP?
Chronische Pankreatitis
ERCP (Goldstandard) 5% Komplikationen, Sensitivität 85-95%, Spezifität 80-100%
29.09.2016
Chronische Pankreatitis
Correlation between the Cambridge score
and the peak lipase concentration
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:1432–1436
Chronische Pankreatitis
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 !
Chronische Pankreatitis
Endoscopic therapy
Chronische Pankreatitis
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
Chronische Pankreatitis
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
Dumonceau J-M et al. ESGE Guideline for endoscopic treatment of chronic pancreatitis… Endoscopy 2012; 44: 784–796
ESGE Clinical Guidelines: MPD
Chronische Pankreatitis
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
Dumonceau J-M et al. ESGE Guideline for endoscopic treatment of chronic pancreatitis… Endoscopy 2012; 44: 784–796
ESGE Clinical Guidelines: MPD
Chronische Pankreatitis
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.
Dumonceau J-M et al. ESGE Guideline for endoscopic treatment of chronic pancreatitis… Endoscopy 2012; 44: 784–796
ESGE Clinical Guidelines: MPD
Chronische Pankreatitis
ESWL
Chronische Pankreatitis
Spyglass® and EHL
Ito K et al. BioMed Research International 2014
Chronische Pankreatitis
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
ESGE Clinical Guidelines: MPD
Chronische Pankreatitis
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
ESGE Clinical Guidelines: MPD
Chronische Pankreatitis
Chronische Pankreatitis
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
Chronische Pankreatitis
Chronische Pankreatitis
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
Chronische Pankreatitis
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
Chronische Pankreatitis
Successful Management of Benign Biliary Strictures
With Fully Covered Self-Expanding Metal Stents
33
Stricture resolution after FCSEMS placement. Devière et al Gastroenterology 2014
Devière et al.Gastroenterology 2014
Chronische Pankreatitis
Successful Management of Benign Biliary Strictures
Fully Covered Self-Expanding Metal Stents
34
Temporal pattern
of FCSEMS
migration Devière et al Gastroenterology 2014
Patients
without
migration
(%)
Devière et al.Gastroenterology 2014
Chronische Pankreatitis
Successful Management of Benign Biliary Strictures
Fully Covered Self-Expanding Metal Stents
35
Patients with Stent- or Removal-Related Serious Adverse Events Devière et al Gastroenterology 2014
Devière et al.Gastroenterology 2014
Chronische Pankreatitis
CP-Patient A before B during C after FCSEMS
Devière et al.Gastroenterology 2014
Chronische Pankreatitis
CP-Patient A before B after FCSEMS C after removal D after multiple plastic stents
Ogura T et al. Ther Adv Gastroenterol 2016
Chronische Pankreatitis
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
Chronische Pankreatitis
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
Chronische Pankreatitis
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
Chronische Pankreatitis
Danke für Ihre Aufmerksamkeit !
Chronische Pankreatitis
Biliary stenting: ESGE Guidelines 2012
Dumonceau J-M et al. ESGE Clinical Guideline for biliary stenting… Endoscopy 2012; 44: 277–292
Chronische Pankreatitis
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
Chronische Pankreatitis
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
Chronische Pankreatitis
29.09.2016 Referent
CT: chronische Pankreatitis