So, we will move on to our lectures. Our first lecture will be given by Dr. Raj Shah from the University of Colorado, Endotherapy and Chronic Pancreatitis, How and When Can We Make an Impact? And again, I encourage you to add your questions through the poll everywhere. Thank you, Amrita, for this kind invitation to speak to you. 45 minutes, I mean, I would have done just the synchro anatomy by that time. These are my disclosures. So my approach to impact chronic pancreatitis is to determine the etiology initially, including genetic testing when appropriate. Cessation of alcohol, I think, is a must, unless there are some aspects of symptomatic pseudocysts, frequent hospitalization from obstructing pancreatic stones or to exclude neoplasia. Then we may begin endotherapy in those cases. Otherwise, we really need alcohol to be stopped prior to commencing therapy. Cessation of tobacco tends to be a bit of a longer-term approach. Most patients, regardless of lung cancer and cardiac disease risk factors, when we tell them that there's a risk of pancreatic cancer and smoking, they tend to listen more to that than anything else. So, I do still spend some time talking to patients about not smoking. And then really assessing how motivated the patient is to minimize narcotics or to avoid them. I think that can help tailor how much investment of resources and time that we're going to take into this algorithm of managing patients that are symptomatic from chronic pancreatitis. And is the pancreatic duct dilated? And if so, we tend to perform EUS to exclude neoplasia. Even if the duct is non-dilated, we'll use EUS in that setting, and then ERCP and pancreatic extending. If the duct is non-dilated, then we go the route of alternative pain management options, including occasionally considering a short trial of non-encapsulated enzymes. The data is really quite limited in that recommendation. In highly motivated patients, I'll utilize NSAIDs and see the benefit. Antioxidants have been utilized as well, neuromodulators. And still we'll use selectively ciliac plexus block as a trial to see if this would help in their pain. So this is a 78-year-old female with chronic pancreatitis, increasing pain and weight loss. You can see a markedly dilated pancreatic duct. And on EUS, you can see asymmetrical thickening of the pancreatic duct wall and sampling was suspicious for adenocarcinoma. Resection confirmed that. So utilizing EUS in these patients is helpful to exclude neoplasia. There are limited guidelines on endoscopy and symptomatic strictures in chronic pancreatitis. In European guidelines, they recommend a 10-friend stent uninterrupted for one year. We tend to do upsizing gradually over the course of a few months or six months, and then multiple plastic stenting is often required to resolve these strictures. I tend to avoid fully covered metal stents in this case, but the quality of evidence here is low quality. Biliary strictures are pretty early on utilizing fully covered metal stents. Pseudocystis transmural drainage is exactly effective in managing these patients. If a disconnected pancreatic duct tail syndrome is suspected, then long-term double pigtail stents are utilized. I've been doing that quite regularly over the time of my practice, and it's good to see some guidelines that suggest that that might be beneficial. This is a patient with a pancreatic head stricture with upstream pancreatic ductal dilatation stented, and subsequently you see some additional stricturing here toward the genu. A fully covered metal stent is placed in a pretty reasonable position. And then on follow-up with stent removal, you see complete ductal cutoff. And subsequently, the patient did well for about a year, a little more than a year, sort of having recurrent symptoms. And this is the follow-up pancreatogram. Turns into almost a pancreas divism, an acquired divism. She was young enough and dilated duct enough that she went on to lateral pancreatic adjunostomy. So I generally, it's not just this case, but other cases as well, I avoid fully covered metal stents in general in the pancreatic duct. For pancreatic stones, the composition is quite firm. It's an internitis of nickel, iron, and chromium surrounded by calcium carbonate. The pain is thought to be related to stones obstructing the duct, causing intraductal and parenchymal hypertension. And decompression of that is thought to improve pain. So most of these stones, because of their composition, require fragmentation, either external lithotripsy or intraductal lithotripsy. And guidelines on this from the European group or society is to utilize ERCP or ESWL's first line for obstructed main pancreatic duct stones in the head or body of the pancreas. If it's focused primarily in the tail, then endoscopic therapy is usually not considered. If they're quite symptomatic, then surgery tends to be the option there. If they're obstructed stones larger than five millimeters, they recommend ESWL. And then ERCP for smaller stones or radiolucent stones, and this is moderate quality evidence. Now they recommend restricting the use of endoscopic therapy after ESWL to patients who do not have spontaneous clearance of pancreatic stones after adequate fragmentation by ESWL. I tend to do ERCP in all these patients. I tend to do more pancreatoscopy and ERCP for these patients, partly related to access to ESWL and partly related to whatever the local expertise and experience may be. But I believe that trying to extract and clear all of these stone fragments is essential to try to reduce the risk of stone recurrence and also treating any underlying structures. If you don't adequately treat the downstream structures, these stones are going to recur just about every time. Pancreatoscopy guide a lithotripsy when ESWL is not available. And as I mentioned, I do ERCP as first line for all these stones. So this is a clinical case, markedly dense calcifications in the head of the pancreas, multiple calcifications. And this video shows calcifications here concentrating in the head. Some of these are introductal. Some of them are parenchymal. And frankly, without a pancreatogram, it's really hard for me to tell which ones are going to be introductal or not based on a CT scan alone. And along this video, which I'll fast forward here a bit, you can see curling of the wire. You don't necessarily need to get the wire all the way beyond the stone. Sometimes you just have to get it to the level of the stone, dilate any downstream structures, and then with pancreatoscopy, we're able to visualize this obstructing stone. Sometimes it can be difficult with a laser or EHL fiber passing through the pancreatoscope. And so you may come out and freehand the advancement of the EHL or laser fiber to try and then access the pancreatic duct, target the stone for successful introductal lithotripsy, which I'll break up here for a moment there. Cases with EHL, pretty soft stone. I generally tend to use laser for these cases because they tend to be quite hard. This was more of a genetic chronic pancreatitis. Patients tend to have a little softer stone that allows for adequate fragmentation. Celiac plexus block, I mentioned I use selectively the very low quality of evidence in patients who have non-ductal hypertension, chronic pancreatitis, non-dilated pancreatic ducts. I do utilize this, especially if neuromodulator therapy has been unsuccessful in managing their pain, and select group of patients will get benefit. I don't keep repeating it if it doesn't work, but in the patients who get at least a two to three-month response, I'll consider repeat block. And then this is a pancreatoscopy-guided laser dissection of an obstructing pancreatic duct stricture. And it's really this idea of maybe pancreatic endotherapy will help and preserve the pancreas. And this was Emily Yonica's video. She did an excellent job with this over the course of her time in Colorado. And I'll try to fast forward this, but this is a 74-year-old with chronic calcific pancreatitis demonstrating a large 15-millimeter pancreatic duct stone with upstream ductal dilatation. And CT shows tail calcifications. We're not so much trying to target all of these calcifications, but this one stone, and you can maybe appreciate stricture. And so this example, a pancreatogram, you see a tight stricture, an impacted stone, very difficult. You might be able to get a wire across. In this case, we were unable to. If you can't get a wire across, you're pretty much not going to be able to perform a stricture dilation. So in this case, we did a staged procedure where we left a stent just to the level of the stone, but not able to get beyond it. Symptoms did not improve much. So we performed pancreatoscopy and utilizing laser, and usually a soft tissue setting, you can perform laser dissection usually in three quadrants to try to open up that stricture. You can't balloon dilate this. So you have to utilize a technique such as laser strictureplasty, which is relatively new. We have a few publications on this limited case series, but it helps to open up the duct. And just that cautery effect on the stenosis may help to open up and increase the patency of the lumen that will then allow for access to the stone. You see that there's a small adjacent pseudocyst. And then you can see the pancreatic duct in the tail finally show up. And subsequently, in follow-up, we do additional intraductal lithotripsy, followed by improvement, which is the most important, improvement in the clinical symptoms. And you can see the before and the after. We're really preserving about half of the pancreas here. That patient went on to resection, which would have been a neck, body, tail resection. They would have been diabetic for sure. So we're preserving the pancreas with this advanced techniques of pancreatoscopy. And these are my final comments. Thank you very much. Thank you so much, Raj.

endotherapy

chronic pancreatitis

genetic testing

pain management

pancreatic stones