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Prince of Wales Department of Surgery Journal Club

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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

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Title: Prince of Wales Department of Surgery Journal Club


1
Prince of Wales Department of Surgery Journal Club
  • Richard Smith
  • Monday 2nd April 2007

2
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

3
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
    200531238-1244

4
Background
  • 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

5
Aim
  • .. 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.

6
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
    significance
  • Randomised into EUS or ERCP (lt24 hrs of admission)

7
Criteria
  • 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

8
Study Design
  • Once randomised, all data collected by a single
    research assistant
  • Biochemistry tests ordered, vital signs recorded,
    routine transabdo US for all patients

9
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

10
ERCP Group
  • Diagnostic ERCP within 24 hrs
  • If choledocholithiasis detected, ES and
    extraction were performed

11
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)

12
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)

13
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
    instrumentation

14
Results- MM
  • 3 deaths- 2 in EUS 1 in ERCP
  • Related to severity /or comorbidities, not to
    the procedures

15
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
    cannulations
  • Finding choledocho- by EUS encourages the
    endoscopist to adopt an aggressive approach

16
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

17
Evaluation
  • 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

18
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

19
Thank you
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