Prince of Wales Department of Surgery Journal Club - PowerPoint PPT Presentation


PPT – Prince of Wales Department of Surgery Journal Club PowerPoint presentation | free to view - id: 3d811e-MWViN


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Prince of Wales Department of Surgery Journal Club


Prince of Wales Department of Surgery Journal Club Richard Smith Monday 2nd April 2007 Endoscopic Ultrasound Somewhat recent diagnostic tool, developed for staging of ... – PowerPoint PPT presentation

Number of Views:141
Avg rating:3.0/5.0
Slides: 20
Provided by: sesiahsHe


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Prince of Wales Department of Surgery Journal Club

Prince of Wales Department of Surgery Journal Club
  • Richard Smith
  • Monday 2nd April 2007

Endoscopic Ultrasound
  • Somewhat recent diagnostic tool, developed for
    staging of gastric malignancy
  • Recent review article in ANZJS (March 2007),
    discussing its use in upper GI cancers,
    particularly for determining surgical candidates
  • Also becoming useful in benign diseases, such as
    chronic pancreatitis

Comparison of Early Endoscopic Ultrasonography
and Endoscopic Retrograde Cholangiopancreatography
in the Management of Acute Biliary Pancreatitis
A Prospective Randomized Study
  • Chi Leung Liu, Sheung Tat Fan, Chung Mau Lo, Wai
    Kuen Tso, Yik Wong, Ronnie T. P. Poon, Chi Ming
    Lam, Benjamin C. Wong and John Wong
  • Clinical Gastroenterology and Hepatology

  • ERCP and sphincterotomy (ES) useful in acute
    pancreatitis (AP) with biliary cause
  • If used in all unproven cases, leads to
    unnecessary ERCPs
  • Significant morbidity and mortality
  • Previous studies have shown EUS is better than
    transabdo US, and similar to ERCP, in diagnosing
    cholelithiasis in AP
  • Best at diagnosing microlithiasis
  • Also has role in selecting patients with
    choledocholithiasis for ERCP

  • .. To evaluate the role of EUS in the management
    of patients with acute pancreatitis and to assess
    whether early EUS examination would reduce the
    morbidity by avoiding unnecessary invasive
    diagnostic ERCP.

Study Design
  • Single centre (Queen Mary Hospital, Hong Kong)
  • Prospective, randomised, controlled study
  • July 2001- December 2003
  • 140 patients with 1st episode AP, suspected
    biliary cause
  • Estimated requirement for adequate power and
  • Randomised into EUS or ERCP (lt24 hrs of admission)

  • Exclusion- recurrent pancreatitis (14)
  • Severe cholangitis/ septic shock (8)
  • Post ERCP pancreatitis (19)
  • Hyperlipidaemia (2)
  • Chronic alcoholism (3)
  • Dx delayed gt24 hrs (5)
  • Refused (16)- Total excluded67
  • Inclusion- abdo pain amylase gt3x normal
  • Deranged LFTS
  • No other cause identified- Total no. 140

Study Design
  • Once randomised, all data collected by a single
    research assistant
  • Biochemistry tests ordered, vital signs recorded,
    routine transabdo US for all patients

EUS Group
  • EUS within 24 hrs
  • When EUS detected choledocholithiasis,
    therapeutic ERCP with ES and extraction were
    performed under the same sedation
  • When not detected- conservative Mx

ERCP Group
  • Diagnostic ERCP within 24 hrs
  • If choledocholithiasis detected, ES and
    extraction were performed

Results- Detection of Stones
  • Biliary cause identified in 110 patients
  • Biliary tree exam successful in all patients in
    EUS group
  • CBD cannulation failed in 10 of the ERCP group
  • EUS group- 25 choledocholithiasis
  • All confirmed on ERCP same session
  • 4 required 2nd session to complete clearance
  • 51 cholecystolithiasis (confirmed with surgery)

Results- Detection of Stones
  • ERCP group- unsuccessful in 10 patients
  • repeated, 2 failed again
  • Choledocho- in 20, cleared with ES and extraction
    in 19 (other had surgical extraction)
  • 48 cholecysto-, US ERCP missed 6
  • These were later diagnosed by EUS and surgery
  • 11 patients had no cause found
  • All in EUS group
  • No recurrence or other symptoms of stones after
    follow up (median 26 months)

Results- MM
  • Similar hospital stay (66.5 days)
  • Overall morbidity
  • 7 in EUS group
  • 14 in ERCP group -P.172
  • Main difference was 4x post ES bleeding (required
    therapeutic endoscopy)
  • 2 of these had no choledocho- on direct

Results- MM
  • 3 deaths- 2 in EUS 1 in ERCP
  • Related to severity /or comorbidities, not to
    the procedures

Discussion 1
  • Morbidity of EUS is numerically lower, but not
    statistically significant
  • Authors conclude it could safely replace
    diagnostic ERCP in biliary pancreatitis for
    selecting those for therapeutic ERCP
  • To diagnose choledocho- with ERCP, ES
    instrumentation required (highest morbidity)
  • Successful exam in all EUS, cf 10 failed CBD
  • Finding choledocho- by EUS encourages the
    endoscopist to adopt an aggressive approach

Discussion 2
  • Transabdo US/ ERCP missed 6 cases of
    cholecystolithiasis- not statistically evaluated
  • Advantage over MRI- slightly better results, and
    can progress to ERCP during same session/ sedation

  • No discussion of how many cases were detected by
    transabdo US before EUS
  • Those with no stones found on EUS- never
    otherwise excluded
  • Asian population- authors suggest higher
    incidence of biliary cause for AP, more
    frequently severe presentations

In Practice
  • Is conclusion warranted?
  • ERCP used acutely- only in severe AP with
    suggestion of biliary cause- would a negative EUS
    satisfy the surgeon?
  • Limited availability
  • SVH 1 gastroenterologist able to perform

Thank you