So, our next speaker will be Dr. Shyam Varadarajulu, who is the president of the Digestive Health Institute in Orlando Health, and he'll be speaking on the Endoscopic Management of Acute Pancreatitis. Thank you, James and Peter. So my talk is Endoscopic Management of Pancreatitis. So as you know, in acute pancreatitis, there's no role for endoscopy. It's only the complications that we manage. So these are the baseline facts. I think endoscopy is preferable to surgical and radiological approaches, and it gives you a treatment success that is greater than 90%. Re-interventions, length of stay, re-hospitalization, and costs are all higher when treating necrotic collections. And luminoposing metal stents are comparable to plastic stents, are sometimes even preferable because it's of much shorter duration. So these facts are very well established. So there are three ways that we can manage outcomes in necrotizing pancreatitis. One, we need to decrease the number of interventions that we perform in these patients, because if you look at the Medicare database, the average length of stay for a patient with necrotizing pancreatitis in the United States is 19.9 days. And we can decrease this by doing a couple of things. One, we need to choose luminoposing stents of correct dimension. There are a few things about placement and management. We need to tailor the treatment to an individual patient. And if you have to do necrosectomy, you do it early than later. We can decrease the length of stay by looking at the time to intervention. We don't have to wait for three weeks sometimes. We have to start early nutrition. We have to use percutaneous drainage appropriately as and when required. We need to minimize adverse events, and we need to standardize the follow-up. We don't have any guidelines on any of these things listed here. And finally, recurrence is very important. It's not just managing getting the patient out of the hospital. We shouldn't see them back. And if we see them back, it should mean as an outpatient for something else. And we need to decrease the recurrence by managing the ductal problem. If we don't do that, then these are patients who will come back to us over and over. So let's focus on the first one, reinterventions. So stents are of various types. When you've managed necrotic collections, I think you should just settle with 15 or 20 millimeter stents. The longer stents should be in patients where the fluid collection is borderline. More than 10 or 15 millimeters away from the GI lumen, you go for a long saddle stent. The 20 millimeter stent should be preferably deployed when you think you're going to perform a necrosectomy at the index session. Even otherwise, there's no downside to using a larger stent. Second is let's focus on, this is going to be a video of a patient. I can move this mouse. So this is a patient who comes with a fluid collection. And you can see that the collection is away from the transducer. It's approximately about 20, 22 millimeters. So now what I'm trying to do is I've already placed a metal stent. I'm not inside the cavity. It's hanging somewhere down. So once you do that, what you do is you put in a balloon right through the stent. And the balloon should be about four centimeters in length. And then you can dilate the tract. Because after all, what you're doing is going beyond the stent to mature the tract to gain access. And once you do that, you will land up straight into the fluid collection. So that this rule, that it has to be within 10 to 15 millimeters, sometimes can be compromised and broken. You can place a stent, dilate the tract, you will gain access into the cavity. And if you want, you can put in another stent through it with a double-pigtailed plastic. But generally not required. So the second is, where do you place your stents? Very often, we should control our enthusiasm. You just don't see a collection and immediately place a stent. You want to avoid all the proximal portions and go to the very distal part of the stomach. And this is for the following reason. So this is a patient who comes to you with a fluid collection. You can see this fluid collection actually from the gastric cardiac. Now you're going down all the way towards the antrum. And it's very important that when you place stents, you start at the antrum because those are the places through which you can access the cavity should you desire to perform a necrosectomy at a later time. If you place a stent at the cardiac, you're not going to be able to access it much easier. So here you can see us going and placing a stent somewhere from the distal stomach. And once that is done, it drains very, very well. On the other hand, in another patient who was referred to us with another luminoposing stent from an earlier facility, you can see that the stent is placed so proximally, it's almost impossible to gain access to perform a necrosectomy. In these cases, you will be forced to place a percutaneous drain and perform sinus tract necrosectomy. So always go distally to place a stent. Irrigation is key. So stent placement is only the first step in treating a patient. So you can see there's a lot of debris in this patient, close to 40% to 50%. And as soon as a metal stent is placed, what you should do is to spend another 10 minutes. And what you should try to do is you should try to irrigate and try to decrease this wall. My colleague is doing a narration on this. So you can see this collection there. In this particular case, it was not well irrigated. And the patient comes back to you after two days. And when you do an EUS on this patient, you can see a debris sitting right at the opening of the stent, precluding drainage. So this is the reason that irrigation is key. So place a stent distally, irrigate the stent. And when you place stents, it does not have to be within 10 to 12 millimeters. You can access distant collections by diluting it. Finally, I think it's important to have a protocol. Just placing a stent is not sufficient. So if you're finding your pancreatic pseudocyst, I think you can place either aluminum posing metal or a plastic stent. But if the patient has got a calcification in the pancreas, they always will come back unless you do an ESWL and fragment the stone. So in these particular cases, it's preferable to place plastic stents so that they can be left in situ indefinitely. If this is a unilocular collection, sure, a single stent is fine. But if you've got two discrete collections separated by a clear septation and they don't communicate with each other, then you have to perform multi-gate technique by placing multiple stents. If the patient has got a disconnected pancreatic duct, but you've got a viable pancreas on the tail and a fluid collection on the head, these collections tend to recur. And in these particular cases, either you should place a metal stent, and once the collection has resolved, you exchange it for a plastic stent, or alternatively, you perform drainages at two sites. You place aluminum posing metal stent and a plastic stent, so that when the patient comes back, you remove the metal stent and leave the plastic stent indefinitely. Finally, in patients who have got collections both near the pancreas or the lesser sac and also tracking to the flank, you need to perform the dual modality drainage, where you place percutaneous drains and you perform an endoscopic drainage so that you can expedite treatment and discharge the patient as quick as possible from the hospital. Does the strategy work? I think in a study of about close to 400 patients, we have clearly shown that when you use this integrated approach to management of patients with pseudosis and necrosis, you've got a pretty good success rate with the strategy, close to 95% compared to just not using a strategy at all and managing only with plastic stents. So plastic stents do have a role in management of pancreatic fluid collections in 2022. If you've got a ductal obstruction, if there's a disconnected duct, these are going to be the stents of choice that will prevent recurrence. What happens if the collections are multiple? You've got a fluid collection like this, so this will be encountered in 15% of the cases, and that is a way to manage these patients. I think when you perform an EVOS on these patients, you can see there's a huge collection right close to the jejunum, and then when you retract the scope into the stomach, you will still find collections on either side of the stomach. It doesn't mean that these are all discrete collections. Very often what happens is that the CT scan will not be able to distinguish it, and you can see this communication here through a very, very small area. So generally what you should do in these patients is you don't want to drain through the jejunum. It carries a risk of perforation because the jejunum wall is very, very thin. Always go through the stomach. Find out collections of different density, and in this particular case, that is clearly a collection with some necrotic debris in it, and then once you drain it, you see good drainage. Then you go on the contralateral side, and then you drain a second collection, and you see it's got a different density to it compared to the previous collection. And after you drain them both, here is a much more clear fluid. So one is a reactive collection. The other was necrotic. They don't communicate with each other, and then when you drive your echo endoscope close to the distal duodenum, you will find that the collection you previously saw has completely disappeared. So try to resist the temptation to drain collections through the small bubble because they do carry a finite risk for perforation. When do you perform necrosectomy? I think the timing of necrosectomy is important. You do the index procedure when you deploy a stent and there is no drainage. Then you've got a problem. You're going to cause, yeah, you convert a sterile to an infective necrosis if it's not already infected, or if there's more than 35 to 40% debris, they always generally tend to require necrosectomy. So these circumstances, you go for an index intervention. In other patients, if they have only minimal debris, then you can wait on these patients. What are the symptoms for re-intervention? If the patient has got subsistence, organ failure, failure to thrive, on re-imaging at 72 hours, you've got persistent collection and the fluid and the cavity has not decreased by greater than 25%, then you re-intervene. So you must have a method on when to intervene at the first sitting or at a subsequent sitting. So we talked about all those things on re-interventions because the earlier you do necrosectomy in a select group of patients, you can send them home rather than wait for a miracle to happen. So now let's see what we need to do to decrease the length of stay. So very often the patient will come to the hospital with a few days or weeks of pancreatitis. Do we have to always wait? In this particular case, it's a very immature collection. There's no wall. There's nothing to do for this patient except to start enteral nutrition. Here you have a wall, but it's fairly immature on the lower portion. This is called an acute necrotic collection. You can drain them, but don't place plastic stents because if the guide wire is going to go through the contralateral area here, you will cause much soilage of the lesser sac. In this particular case, the wall is well-formed, and sure, this is a wall of necrosis through which you can place any kind of stent that you want to place. And this is a patient who came to us with a trauma after a motor vehicle accident, and this is at 48 hours. They told me to see if I can preserve the pancreatic duct so that this patient will not have an atrophic pancreas because of disconnection. So you have to be very careful. You put in preferably a tandem cannula. There's not a sphincter term. You pass in a slim guide or glide wire, and then once you are able to bridge the site of leak, you deploy the stent. Then you can preserve the pancreas, hopefully, in these patients. Subsequently, the patient still ended up getting a fluid collection on the body. This is on the fourth day. But I can see a room pretty clear around the collection. So I don't have to wait for four weeks in this particular case. So on the fourth day, you deploy your aluminum-posing metal stent, patient did fairly well, and then was discharged within a couple of days. So this rule that you have to wait for four weeks may not necessarily hold true for all situations. I think if you've got a marginal room, you can intervene, and I think patients with trauma behave differently than those patients whose etiology is acute pancreatitis. And there's a study from Marty Freeman's group that clearly tells you that instead of waiting for four weeks, if you intervene early, your outcomes are pretty much the same, except that you can have some infectious complications early on. But overall, patients will do equally well. Enteral nutrition is important. In severe acute pancreatitis, when the patient comes to you and there's no fluid collection, never, ever place a gastrointestinal feeding tube. If you do that, a pig jay is placed. You develop compartment syndrome over a period of time as a natural evolution of the disease. The bumper is pulled away, and then you've got free peritonitis. So it's very important always in these cases that early stage before a collection is walled off, nasojejunal feeding tube must be placed. Once the collection is walled off and the patient is doing okay, then it is all right to go and place a pig jay feeding tube. We have got about eight or nine cases of perforation by early nutrition through a pig jay, so always resist the temptation. Pericutaneous drainage, yeah, this is a necessary evil. We have to do it. But the problem is this. This is a Medicare database that I've just reviewed for UEGW, and you can see in close to 1,500 patients across the United States, when you do an IR drainage compared to an endoscopic drainage, the mortality is actually independently high, hospitalization is high, the length of stay is significantly longer, and the costs for interventional radiology is more by $10,000. And these are facilities that can perform both drainages. Why am I showing it? Very often we don't see these patients. Hospitalists and general surgeons in every facility should be educated so that patients will be triaged preferably to an endoscopist rather than a pericutaneous drainage. If they take the pericutaneous route in collections that are amenable to both treatment modalities, these are the differences you will observe. If you place a pericutaneous drainage and if you've got a good relationship with your radiologist, there are four things that are important. One, please place the pericutaneous drain not through the intercostal cartilages. Once I do that, you can't do anything else because the patient will have severe pain and you can't upsize the drain. Two, tell your radiologist, give me nothing less than a 16 French drain. Why? If you place a 16 French drain, the tract matures faster and you can perform a sinus tract necrosectomy much, much easier. Immediately upsize the drain to 24 French for a period of 48 to 72 hours because it drains much better and it can evacuate solid debris if connected to suction. Fourthly, if the collection has got more than 35% necrosis, you can proceed directly with an endoscopic sinus tract necrosectomy. And if you are not comfortable, you can have your surgeon perform a ward for you. But most surgeons trained in the United States are not comfortable performing wards. I think we do a much better job than them. How do you do a sinus tract necrosectomy? I think it's a very rewarding treatment that everybody should be aware of. You just remove the 24 French drain that has been previously placed. But before you do that, you remove the sutures and you put in a 035 inch guide wire that the tip should be fairly flexible but should be a stiff guide wire. And you can see pus exsanguinating through the sinus tract. Once that is done, it is not possible to pass a scope. You should pass not a diagnostic but a therapeutic gastroscope that is fitted with a cap. Prior to that, you need to dilate this tract and you have to go all the way up to 48 French using savory dilators. Once your dilation is done, then you put on a cap-fitted gastroscope and you advance it. As you advance the gastroscope through it, you have to be a little bit careful because the walls of the tract are not very mature. So you can land up and see organs you don't want to see if you don't follow the tract. So you follow the guide wire directly inside and then once you are in, it pretty much follows the same thing. You've got the necrosis there and then you perform debridement the standard fashion. Debridement consists of three things. One, cap-assisted therapeutic gastroscope, preferably with a snare. If the debris is very adherent, you use captivator snare. If it is not adherent, you can use any oval snares. Secondly, you need to evacuate them. And evacuation is not going to work with roughness and so on. You need to suck them into the cap and then you keep the snare closer to it and you remove them as much as possible. And finally, never use hydrogen peroxide at the beginning. It causes so much foam that you will lose visualization. Always use normal saline. There is no evidence, but you can use gentamicin mixed with normal saline and you complete the procedure at the very end by using hydrogen peroxide because it's a good sterilization medium. You want to minimize complications in these patients. So people will always write K-series and tell you, well, it's great. I don't see complications. Not actually. This is a patient 48 hours after a pseudo-sustainage has got so much of bleeding. So do not review these K-series and registries. These are flawed data. Data comes from good quality randomized trials. And if you follow these patients and during randomized trials, we have clearly seen that complications do happen. So you never want to leave luminoposing metal stents for more than three to four weeks. Exchange them for double-pigtailed plastic stents unless you have a lot of residual fluid collection. And here you can see that within 48 to 72 hours, we had pseudoneurysm right by the luminoposing stent causing a friction against the local vasculature. And then we coiled it. Guess what? The patient did well and within 72 hours, bled again. And once more, we had massive bleeding in this patient. And the patient subsequently had seven recurrent episodes of bleeding all within one hospital stay. So luminoposing metal stents are not without problems. They do cause bleeding by compressing the vasculature adjacent to it. And this has to be watched out. Follow-up after index intervention. This is important. We always treat patients and then we hope that the patient looks better. There's always an objective way to follow the patients. Most of these cases are inpatients when they are necrotic. So we get a 72-hour CAT scan in every patient. And you also want to look at their clinical symptoms. Do they have SIRS? Do they have sepsis? Radiologically, is there a more than 25% decrease in size of the collection? If none of this has happened, you want to re-intervene. If it is liquid debris that you see, you drain them. If it is solid debris, you perform a necrosectomy. Repeat this at 72 hours and follow the algorithm. There's a much better way you will have control over the patients. This is not a randomized trial, but this is data from my group, the MISER trial. And on the right side, you see the tension trial. But what you will find is that patients in the MISER trial, where ASA class 3 or 4, 95% compared to only 5% with the tension trial from Netherlands. The CTCVRT index was much higher in our patients, 8 to 10 in 97%, compared to only a median of 6 in the Dutch group. Our APACHE scores were higher. But if you look at the number of interventions per patient, it was only a median of 1 versus 3 in the Dutch group. And the length of stay was significantly shorter by close to 30 days with what we did. And the reason is only because the Dutch study is multi-center across 16 hospitals. We can manage them within a single center. So if you have a strategy to manage your patients, you can fix them faster and you can get them home sooner. So one of the burning questions is, when you do fluid collection drainage, do you have to do a necrosectomy then and there, or do you have to wait it out and see a step-up approach? This is a multi-center randomized trial that we are conducting. There is a 70-patient sample size, and we are now waiting for the 70th patient. So hopefully we'll have the final data probably for the next DDW. And definitely this study will be completed next week. And lastly, recurrence. So the patient goes home. What you want is, you don't want to see the patient again in the hospital. And very often it does happen. How many patients come back with recurrence of fluid collection? It's about 18 to 23 percent. How do you fix them? There are three things. One is pancreatic duct problem, where there is a disconnected duct, it's an obstructed duct, or it's a disrupted duct. And there's a major difference between all three. So this is a patient with a disconnected pancreatic duct that you can see. You've got a necrotic collection. The collection is resolved. The metal stent is removed. And very often you may have a problem because the cavity is collapsed. So here you see your residual pancreatic gland. And then you've got some sort of a necrosis in the middle. And then you've got a pancreatic duct on the top. So this is a classic example. And this is the EUS correlate of what you will see on an MRI. So in this patient, what you do is you remove the aluminum posing metal stent, you coil a guide wire, and you should preferably place one or two plastic stents. You can argue, does this concept work? So to prove this concept in this particular case, you can see us injecting the pancreatic duct immediately after the aluminum posing metal stent was exchanged for a plastic stent. And you will find that the contrast that is injected with the FNA needle into the tail of the pancreas will seep out into the gastric wall, proving that this problem is real. See a leak happening into the cavity. So therefore, a disconnected duct is real. The second problem that you're going to have sometimes is you'll have an internal fistula in the stomach. OK. I'm almost done, Peter. So you can see there's a fistula that is between the pancreas and the gastric wall. And unfortunately, you should make that fistula much larger. Otherwise, the patient will have pain. This collection will leak into the lesser sac and will never eject out. So once you see a fistula, then from the stomach, you want to identify the fistula by injecting contrast. You want to coil a guide wire into the fistula. You want to dilate the tract. And you want the disconnected gland to communicate with the gastric wall via the gastric fistula. And this will decrease their pain. If you don't do that, once again, all these problems will happen. If you don't exchange the luminal opposing metal for a plastic stent, then you may have to do a pancreatic gastrostomy, which is probably the most challenging interventional EUS procedure. Here you go and find the disconnected tail. You inject the pancreatic duct with a 19-gauge needle. You coil a guide wire into the pancreatic duct. You create a dilation between the stomach wall and the residual pancreas. And then you perform a pancreatic gastrostomy by placement of a single pigtail plastic stent between the residual pancreas and the tail and the gastric wall. And then you've got the final option, if the pancreatic duct is obstructed. And this you will not find with necrosis. Very often you will find this with chronic calcific pancreatitis with obstruction of the main pancreatic duct. This is a pretty straightforward case. You will generate your EUS on this particular patient. There is a common bile duct. That is a pancreatic duct. And as you retract the scope, you will find a calcification right in the pancreas. And immediately distal to that, you will find a fluid collection. And that is your pseudocyst. So this can be confirmed by an ERCP. And this was done purely for educational reasons. And you can see that the duct is completely cut off. In these patients, then you have to decompress the tail using a plastic stent. Because what is the point of placing a metal stent? Once you remove the luminoposing stent, the collection is going to come back. So in these cases, plastic stents should be placed as index treatment measure. Last slide. I think this is a patient who was presented to us for a bile duct stone from an outside facility. But then when you see, actually, yeah, the stent is unfortunately in the bile duct. But they went through the pancreas and into the bile duct. And this patient has got necrosis in the pancreatic head region. So this is a very challenging ERCP. This patient can develop a completely atrophic pancreas and go through hell. But if you're a good ERCP, you'll be able to get a wire across the, after removing the plastic stent, through the disconnected pancreatic duct all the way to the tail. And once you bridge it, the patients will do well. So I will end with this slide. If you're not read this manuscript, you have to read it. It's a pretty decent review on what protocol you need to have for these patients. It's well described. And this probably will help you manage your patients. Thank you.

endoscopic management

acute pancreatitis

complications

necrotizing pancreatitis

stent placement

endoscopic drainage