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Prince of Wales Department of Surgery Journal Club

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

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Prince of Wales Department of Surgery Journal Club

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  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 it’s 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 2005;3:1238-1244

  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 (<24 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 >24 hrs (5) • Refused (16)- Total excluded=67 • Inclusion- abdo pain + amylase >3x 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- M&M • Similar hospital stay (6:6.5 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- M&M • 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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