Intl ACGVGR Duvvuru Pancreatitis

3/2/2023
Welcome
Nalini M. Guda, MD, FACG
Mahesh K. Goenka MD, FACG
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American College of Gastroenterology

1
3/2/2023
Endoscopic Management for Chronic Pancreatitis
D Nageshwar Reddy MD, DM, D.Sc, FAMS, FRCP, FACG, MWGO
Asian Institute of Gastroenterology
Hyderabad, India.

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3/2/2023
Chronic Pancreatitis : Stones & Strictures
Intervention : Indication - Pain
Rx
Medical – Endoscopic – Surgical
Ductal / interstitial
hypertension
Nociception
Central
neuroplasticity
Local oxidative
stress
Pancreatic neuropathy
neuroplasticity
Local inflammation
Schematic representation of the conceptual framework of pain mechanisms in chronic pancreatitis.
Talukdar R et al World J Gastroenterol 2013

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3/2/2023
Pancreatic Stone Extraction

4
3/2/2023
Chronic Calcific Pancreatitis - ESWL
For treating patients with uncomplicated painful chronic pancreatitis and

radiopaque stones≥5mm obstructing the MPD, the ESGE recommends ESWL
as a first step, immediately followed by endoscopic extraction of stone fragments
Evidence level 1+ Recommendation grade B
Endoscopy 2019
10

5
3/2/2023
Factors influencing Success Rate
Patient Factors Technical Factors
• Stone Size & Density • Operator Experience
• Presence of Stricture • Type of Lithotriptor
• Duration of Disease • Epidural Anesthesia
• Use of Narcotics • Use of Secretin
11
12

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3/2/2023
Obtained after a median of 1 session with the high power, X-ray focused
machines
Courtesy : Prof . Jacques Devière
13
Fragmenting Pancreatic Stones
Pre ESWL Post ESWL
14

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3/2/2023
Before After
Courtesy : Prof . Jacques Devière
15
Fragmenting Pancreatic Stones

Results
5124
Complete Partial Unsuccessful

Clearance Clearance
3722 (72.6%) 886 (17.3%) 516 (10.01%)
Pancreatology 2019
16

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3/2/2023
Pooled proportion of patients being completely Pooled proportion of stone fragmentation 86.4%
pain free after ESWL 64.2 %
Endoscopy 2020
17
Response to ET No response to ET
Endotherapy effective
(n 28) (n 27)
P value
a
•Head stones
Age at diagnosis, y 47 ± 19 40 ±13 .10
•Disease duration < 5years
Constant pain, n (%) 6 (21) 14 (52) .031
•Intermittent pain
Daily narcotics, n (%) 4 (14) 15 (56) .001
•No narcotic use
b
Duration of disease, mo 4 (1–12) 40 (1–60) .017
•Non smokers / non alcoholics
18

9
3/2/2023
Endotherapy for Chronic Pancreatitis

Long term Clinical Outcomes
56 patients with constant (N=25) or relapsing (N=31) pain treated between
1987 and 1989 and followed for 14.4 years
Annual rate of hospitalization for pain/ stent exchange
Delhaye et al Clin Gastroenterol Hepatol 2004
19
Manu Tandan, DM, D. Nageshwar Reddy, DM, Rupjyoti Talukdar, MD, K. Vinod, MD, D. Santosh, MD, Sundeep Lakhtakia, DM, Rajesh Gupta, DM,
Mohan J. Ramchandani, DM, Rupa Banerjee, DM,K. Rakesh, DNB, G. Varadaraj, DNB, G. Venkat Rao, MS Hyderabad, India
Intermediate follow up Long term follow up
Patients 364 272

Follow up 2 – 5 years 5 – 8 years
Complete pain relief 68.7% 60.3%
Mild to moderate pain 25.8% 35.3%
Severe pain 5.5% 4.4%
Reintervention 28.8% 46.7%
Stone recurrence 14.1% 22.8%
Tandan M et al Gastrointest Endosc 2013
20

10
3/2/2023
Pancreatic Stone Management Problems With

ESWL
• Not broadly available
• Dependent on others (urology)
• Reimbursement issues
Clin Gastroenterol Hepatol. 2021
> Improved Duct clearance
21
Intraductal Lithotripsy
Mansour A et al Gastroenterology 2013
22

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3/2/2023
Intraductal Lithotripsy with Laser
23
Pancreatic Stone Management Problems With

ESWL
↑ Availability
Pancreatoscopy One session
EHL / LL
No dependency
24

12
3/2/2023
Stone Management: Intraductal lithotripsy

Peroral Pancreatoscopy (POP) Guided lithotripsy
• 1999-2020 cases published: 16 studies 383 cases
• Technical / clinical success rate: 37,5%-100%, 76%
• Adverse Event rate: 0%- 30%, 7%
• No difference LL or EHL
• Very heterogenous, mostly retrospective data, mixed population and devices,

mostly short FU for clinical success.
Syed M Saghir et al World J Gastroenterol 2020
25
Surgical Endoscopy 2021
ESWL SOPIL
N:240 N:18
Stone clearance 86% 88%

Adverse event 6.3% 5.6%
No of procedures 3.1 1.6
26

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3/2/2023
Pancreatic Strictures
Cremer Pancreatic Stent
27
Multiple Pancreatic Stents
Single proximal stricture

Multiple stents
Stenting >1year
Courtesy : Prof. Guido Costamagna
28

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3/2/2023
CSEMS for Pancreatic Stricture

(Bumpy Stent)
32 patients – 3 months – 100% resolution
Sung-Hoon Moon et al Gastrointest Endosc 2010
29
EUS Therapy in Pancreatic Pain
• Celiac ganglion
• PPFC drainage
• Pancreatic ductal drainage
• Rendezvous technique
30

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3/2/2023
Aliment Pharmacol 2009
31
Successful Management of Benign Biliary Strictures With Fully Covered Self-

Expanding Metal Stents
Jacques Devière, D. Nageshwar Reddy, Andreas Püspök, Thierry Ponchon, Marco, J. Bruno, Michael J. Bourke, Horst Neuhaus, André Roy, Ferrán
gonzález-huix,lladó, Alan N. Barkun, Paul P. Kortan, Claudio Navarrete, Joyce Peetermans,Daniel Blero, Sundeep Lakhtakia, Werner Dolak, Vincent
Lepilliez, Jan W. Poley,Andrea Tringali, Guido Costamagna
Chronic Pancreatitis
Gastroenterology 2014
32

16
3/2/2023
Fully Covered Self-Expanding Metal Stent vs Multiple Plastic Stents to Treat Benign Biliary Strictures Secondary to Chronic
Pancreatitis: A Multicenter Randomized Trial
Mohan Ramchandani, Sundeep Lakhtakia, Guido Costamagna, Andrea Tringali, Andreas Püspöek, Barbara Tribl, Werner Dolak, Jacques Devière, Marianna
Arvanitakis, Schalk van der Merwe, Wim Laleman, Thierry Ponchon, Vincent Lepilliez, Armando Gabbrielli, Laura Bernardoni, Marco J. Bruno, Jan-Werner
Poley,Urban Arnelo, James Lau,André Roy, Michael Bourke, Arthur Kaffes, Horst Neuhaus, Joyce Peetermans, Matthew Rousseau, D. Nageshwar Reddy
Endotherapy
• Stricture < 3 cm
• Absence of head mass
Gastroenterology 2021
33
Treatment of Chronic Pancreatitis

Endotherapy vs Surgery
Yes
May be
No
34

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3/2/2023
Management of Chronic Pancreatitis
35
Step up Approach
Long- Term pain relief with optimized medical including antioxidants and step-up interventional therapy in
patients with chronic pancreatitis.
Shilmar S, Midha S, Hasan A, Dhingra R, Garg PK
Stop Smoking alcohol

Analgesics
Neuromodulators
Pancreatic enzymes
Antioxidants
No Response
Endo Therapy
No Response
J Gastroenterol Hepatol 2016
Surgery
36

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3/2/2023
CONCLUSIONS: In the long term, symptomatic patients with advanced chronic pancreatitis who underwent
surgery as the initial treatment for pancreatic duct obstruction had more relief from pain, with fewer NEJM 2007
procedures, than patients who were treated endoscopically. Importantly, almost half of the patients who were
treated with endoscopy eventually underwent surgery.
GASTROENTEROLOGY 2011
37
Stone Management: Intraductal lithotripsy

ESCAPE Trial (RCT surgery vs. Endoscopy N=88)
Courtesy Christian Gerges
Issa, Yet al.; JAMA 2020
38

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3/2/2023
Clinical and Translational Gastroenterology 2017
Problems with studies for endotherapy of chronic pancreatitis
• Quality and limitations of the studies
• Heterogeneity of patient population
39
What do we need
• Adequate tools to assess pain
• Sham controlled studies
• Prior drug therapy
• Confounders – alcohol, smoking
• Timing of intervention
• Long term outcome studies
40

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3/2/2023
Dilated Ducts Non Dilated Ducts Complications
ESWL Endotherapy Surgery
Medical therapy
Cx Ganglion Block
Team Work
Physicians Surgeon
Endoscopist Intraventional
Failure
Radiologist
Reddy DN et al Clin Gastroenterol Hepatol 2012
41
Team AIG
42

21
3/2/2023
Questions?
Dr. Reddy
Dr. Guda
Dr. Goenka
43

22

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3/2/2023

Mahesh K. Goenka MD, FACG

Participating in the Webinar

All attendees will be muted and

Type your questions here so

American College of Gastroenterology

Endoscopic Management for Chronic Pancreatitis

D Nageshwar Reddy MD, DM, D.Sc, FAMS, FRCP, FACG, MWGO

Asian Institute of Gastroenterology

American College of Gastroenterology

Chronic Pancreatitis : Stones & Strictures

Intervention : Indication - Pain

Medical – Endoscopic – Surgical

Schematic representation of the conceptual framework of pain mechanisms in chronic pancreatitis.

Talukdar R et al World J Gastroenterol 2013

American College of Gastroenterology

Pancreatic Stone Extraction

American College of Gastroenterology

Chronic Calcific Pancreatitis - ESWL

For treating patients with uncomplicated painful chronic pancreatitis and

Evidence level 1+ Recommendation grade B

American College of Gastroenterology

Factors influencing Success Rate

Patient Factors Technical Factors

• Stone Size & Density • Operator Experience

• Presence of Stricture • Type of Lithotriptor

• Duration of Disease • Epidural Anesthesia

• Use of Narcotics • Use of Secretin

American College of Gastroenterology

Fragmenting Pancreatic Stones

Pre ESWL Post ESWL

American College of Gastroenterology

Courtesy : Prof . Jacques Devière

Fragmenting Pancreatic Stones

Complete Partial Unsuccessful

American College of Gastroenterology

American College of Gastroenterology

Endotherapy for Chronic Pancreatitis

Annual rate of hospitalization for pain/ stent exchange

Delhaye et al Clin Gastroenterol Hepatol 2004

Intermediate follow up Long term follow up

Patients 364 272

American College of Gastroenterology

Pancreatic Stone Management Problems With

• Dependent on others (urology)

Clin Gastroenterol Hepatol. 2021

> Improved Duct clearance

Mansour A et al Gastroenterology 2013

American College of Gastroenterology

Intraductal Lithotripsy with Laser

Pancreatic Stone Management Problems With

American College of Gastroenterology

Stone Management: Intraductal lithotripsy

• 1999-2020 cases published: 16 studies 383 cases

• Technical / clinical success rate: 37,5%-100%, 76%

• Adverse Event rate: 0%- 30%, 7%

• Very heterogenous, mostly retrospective data, mixed population and devices,

Syed M Saghir et al World J Gastroenterol 2020

Surgical Endoscopy 2021

Stone clearance 86% 88%

American College of Gastroenterology

Cremer Pancreatic Stent

Multiple Pancreatic Stents