Endoscopic management in various pancreatic diseases: Basic- anatomy, endoscopy Diagnostic- EUS Cannulation, stenting, sphincterotomy Pancreatic calculi Stricture Pancreatic Pseudocyst management ampullectomy

1. Endoscopic Management of
Pancreatic Diseases
By- Dr. Nihar Chandak

2. Synopsis
Introduction
Embryology of pancreas
Anatomy of pancreas
Basic endoscopic equipments
Endoscopic Ultrasonography (EUS)
Coeliac plexus neurolysis (CPN)
Endoscopic Pancreatic function test
Basics in understanding endoscopic
procedure
• Cannulation
• Rendezvous procedure
• Pre-cutting
Endoscopic challenges
• Juxtapapillary duodenal papilla
• Billroth II gastrectomy cannulation
Sphincterotomy
Endoscopic procedures for pancreatic
calculi
• Stone Extraction
• Mechanical Lithotripsy
• Intraductal Shock wave Lithotripsy
• Extracorporeal Shock wave Lithotripsy
Stricture Dilation
Stenting
Peroral endoscopic debridement
Endoscopic pancreatic cystenterostomy
 Transpapillary drainage
 Transmural drainage
Ampullectomy

3. Introduction
 Pan-Kreas – All Flesh (Rufus Ephesus)
 Sir Andrew Watt Kay called pancreas as ‘The Abdominal Tiger’
because of its complex deep retroperitoneal anatomy and
embryogenesis making it difficult to operate.
 Pancreatic endoscopy has evolved rapidly since the first reports of
endoscopic Sphincterotomy in 1974 (Claassen & Demling, 1974;
Kawai et al, 1974)
 Safrany first performed early endoscopic papillotomy to remove
calculi in the papilla in 1980.
 With the recent advances, several endoscopic procedures have
gained a widespread use in pancreatic diseases.

4. Embryology
 Begins in 4th wk. of gestation
 Develops from two endodermal
primordia
1. Dorsal Bud:
Appears first
Develops into sup. part of head, neck,
body and tail
2. Ventral Bud:
Develops into inf. part of head & uncinate
process
 Between 4th to 8th wk., ventral bud
rotates posteriorly, clockwise to
fuse with dorsal bud.
 At 8th wk., dorsal and ventral bud
fuse.

5. Anatomy P.A.N.C.R.E.A.S =
 Weight- 80 grams (75-125gms)
 Length- 8 inch (10-20cms)
 pH of pancreatic juice- 8
 Total secretions of pancreas- approx. 800cc
 Pancreas lies transversely in the
retroperitoneal space.
 Lie roughly onto 1st or 2nd lumbar vertebra.
 Extending on the right side from duodenum
towards spleen on the left side.

6. Ducts of Pancreas
 Begins at the tail as small channel
 Herring Bone pattern- joined by no. of tributaries on its way at right angle.
 Main pancreatic duct of Wirsung at Major duodenal Papilla (8-10 cm from
pylorus)
 Accessory pancreatic duct of Santorini opening at Minor duodenal papilla (6-
8 cm from pylorus)

7. Basic Endoscopic Equipments

8.  Consist of a control head and a
flexible shaft with a maneuverable
tip.
 The head is connected to a light
source via an ‘umbilical’ cord,
through which pass other tubes
transmitting air, water and suction.
 The suction channel is used for the
passage of diagnostic tools (e.g.
biopsy forceps) and therapeutic
devices.

10. Types of endoscopes
Tip of a forward viewer endoscope
A side-viewer/ Linear EUS with
cannula protruding from the elevator

11. Endoscopic Ultrasonography

12.  Ultrasound transducers have been modified so that they can be incorporated into the tip of
flexible endoscopes.
 These transducers have the advantage of higher frequency and spatial resolution.
 The proximity of the stomach and duodenum to the pancreas allows high-resolution imaging of
the pancreas and eliminates the limits of overlying bowel gas seen in transabdominal
ultrasound.

13. View of normal pancreas on EUS
The echotexture of the pancreatic body is
homogeneous with a fine reticular pattern. The
main pancreatic duct (arrow) is uniform in size
with anechoic margins and without visible side
duct branches. The splenic vein is seen traversing
below the main pancreatic duct
Ventral Anlage: There is distinct difference
in the echotexture of the brighter dorsal
pancreas (D) and the darker ventral
pancreas (V). The aorta (Ao) is traversing
along the ventral pancreas

14. EUS features of chronic pancreatitis: Rosemont's Criteria
Parenchymal criteria Ductal criteria
Major Hyperechoic foci (>2 mm in length/width) MPD calculi (echogenic structure[s] within the
MPD)
Lobularity (≥ 13 contiguous lobules
'honeycombing')
Minor Cyst (anechoic, round/elliptical with or without
septations)
Dilated duct (≥ 3.5 mm in body or >1.5 mm in tail)
Hyperechoic strands (≥ 3 mm in at least 2 different
directions with respect to the imaged plane)
Irregular MPD contour (uneven or irregular
outline and ectatic course)
Dilated side branch (>3 tubular anechoic
structures each measuring ≥1 mm in width,
budding from the MPD)
Hyperechoic MPD wall (echogenic, distinct
structure >50% of entire MPD in the body
and tail)

15. Chronic Pancreatitis-
Hyperechoic duct strand
Foci of pancreatic calcificationHyperechoic foci of pancreatic
parenchyma
Lobularity- Pancreatic
parenchyma is lobulated by
linear hyperechos
Duct irregularity

16. Pancreatic pseudocyst Pancreatic neoplasm
mainly endocrine tumors
Pancreatic Calculi

17. Other Uses
 CBD Calculi
 EUS has progressed from a
diagnostic procedure to an
important therapeutic tool.
 Used in obtaining pancreatic
biopsies or FNA.
 Used in coeliac plexus block to
curb the abdominal pain
caused due to chronic
pancreatitis or pancreatic
malignancy.

18. Disadvantages of EUS:
Requires sedation
Can cause bleeding
Limitations to inaccessible areas
Perforation (less than 1 in 1000s)
Infection (can be prevented by giving pre-procedure antibiotic)

19. Coeliac Plexus Neurolysis
(CPN)

20. Introduction
 First described by Kappis et al. in 1919
 CPN is a chemical splanchnicectomy of the
celiac plexus.
 Its goal is to ablate the efferent nerve fibres
which transmit pain from the intra-
abdominal viscera.
 Celiac plexus is situated below the
diaphragm (ante-crural), surrounding the
basis of the celiac trunk.
 It is composed of a dense network of
ganglia and interconnecting fibres.

21. Procedure
 Linear EUS is introduced into the stomach
to reach the lesser curve in the sub-cardiac
area.
 At this site, it is easy to identify the aorta
under the diaphragm which appears as an
anechoic tube structure in a longitudinal
plane.
 The origin of the celiac axis is seen beside
this.
 Color Doppler can confirm the vascular
landmarks.
 Celiac plexus is not identified as a discrete
structure but is located based on its
position relative to the celiac trunk.
Color Doppler visualization of the celiac
trunk

22.  EUS 20 CPN needle is a special needle
designed for this procedure.
 Closed penetrating tip with some lateral
holes- allow a radial diffusion of neurolytic
agents to both sides of the origin of the
celiac axis with a single injection.
 When the needle tip is in place, an
aspiration test is performed to rule out
vessel penetration before injection.
 Then, 3-6 mL of a local anaesthetic, usually
bupivacaine 0.25-0.75%, is injected first
followed by 15-20 mL of a neurolytic agent
(98%) dehydrate alcohol. EUS 20 CPN Needle

23. Advantages
1. Safer than posterior
percutaneous techniques
because EUS allows direct
access to the celiac plexus
without risk to the vital spinal
nerves, the diaphragm or the
spinal arteries.
2. Useful to curb the pain due to
chronic pancreatitis.
3. In palliation of pts with pain
caused by unresectable
pancreatic cancer.
1. Bleeding
2. Diarrhea
3. Orthostatic hypotension
4. Peripancreatic abscess
5. Reversible paraparesis
Disadvantages

24. Endoscopic Pancreatic
Function Test

25.  Most sensitive diagnostic test for early CP as subtle functional changes occur
at an early stage of fibrosis.
 EPFT collects pancreatic fluid after a 0.2mcg/kg of synthetic secretin (human
or porcine) is injected intravenously.
 Indication:-
1. evaluation of possible early exocrine dysfunction in patients with
abdominal pain
2. the determination of the etiology of steatorrhea
 Most common cause of pancreatic exocrine insufficiency in adults is chronic
pacreatitis.
 Gradual and irreversible replacement of normal pancreatic tissue by
inflammation and fibrosis causes concomitant decrease in exocrine function
of the duct and acinar cells.

26. Procedure
 Gastric fluid is aspirated as completely as possible through the scope
and discarded.
 At time “0” a baseline collection of 3-5 cc of duodenal fluid is
collected in a trap (bottle A). Also at time “0”, the full IV dose of
synthetic secretin (0.2 mcgs/kg, slow push) is administered.
 Intermittent 3-5 cc fluid aspirates are obtained every 15 minutes for
an hour (Bottles B at 15 minutes, C at 30 minutes, D at 45 minutes,
and E at 60 minutes).
 Fluid should be kept on ice and analyzed within 6 hours, or may be
frozen (subzero freeze) and analyzed later for bicarbonate
concentration.

27. Interpretation
 The highest bicarbonate concentration from the 5 samples is
considered the peak bicarbonate.
 A peak bicarbonate <= 80 mEq/L is considered abnormal and
suggestive of exocrine insufficiency.
Duodenal fluid before, during, and after Secretin Stimulation

28. Basics in understanding
endoscopic procedures

29. Cannulation
 Selective cannulation of the bile and pancreatic
ducts is a prerequisite for interventional
procedures.
 Can be performed by
1. Standard cannulation catheters,
2. Sphincterotomes, also called papillotomes
 The main difference between these 2 is that a
sphincterotome has an electrosurgical cutting
wire at the distal end of the catheter.
 Hence, it has the advantage of enabling
immediate sphincterotomy after cannulation.
 It also helps in selective cannulation of the bile
duct by upward bowing in a caudocranial axis.
Standard Cannulation Catheter
Sphinterotome

30.  If free cannulation with a cannulating catheter
fails, guidewire cannulation can be attempted.
 Hydrophilic guidewires with a special slippery
coating are ideal for cannulation because they
minimize trauma to the papilla and more
effectively seek out the path to the desired duct.
 The guidewire is extended several millimeters from
the tip of the cannula or sphincterotome, and the
papillary orifice is cautiously probed with the wire
until it slips into the duct.
Cannulating catheter loaded with
guidewire to assist cannulation

31. Rendezvous Procedure
 Biliary or pancreatic duct cannulation can
be aided by a combined percutaneous
and endoscopic approach k/a
Rendezvous Procedure. (Mallery et al,
2004)
 The bile or pancreatic duct is punctured
transduodenally or transgastrically with a
standard FNA needle loaded with a
guidewire under EUS guidance.
 The wire is advanced anterograde across
the stricture into the duodenum.
 The stent is placed over the wire in the
standard retrograde fashion.

32.  A further variation of the rendezvous approach can be used to
achieve cannulation of the pancreatic duct.
 The minor papilla is used to pass a wire from the duct of Santorini
into the duct of Wirsung and then across the major papilla.
 When cannulation of the major papilla is achieved, the wire is
rerouted from the minor papilla to the main pancreatic duct.
 Advantage: Reduces the chances of Post- endoscopic pancreatitis
(PEP) compared with conventional biliary cannulation.
 Reduced incidence from 3.6% to 2.2%
The American Journal of Gastroenterology 108, 552-559 (April 2013)

33. Precutting (papillary roof incision)
 It is a useful technique to achieve selective
bile duct cannulation when free or wire-
guided approaches fail.
 The objective of precutting is to incise the
roof of the papilla to expose the
underlying opening of the bile and
pancreatic ducts for selective cannulation.
 The endoscopist initiates the papillotomy
by placing the needle-knife at upper
portion of the papillary orifice, near the 12
o’clock position, and initiates the cut
upwards from the orifice.
Precut Papillotomy

34.  For the cannulation of pancreatic duct,
Transpancreatic precut sphincterotomy
is performed.
 Sphincterotome is oriented in the
direction of the CBD a approximately the
11 o’clock position, and is then inserted
superficially into the PD.
Disadvantages of Precut:
1. significant risk factor for
postsphincterotomy pancreatitis
2. there have been isolated reports of
perforation.
Transpancreatic precut sphincterotomy

35. Endoscopic challenges

36. Juxtapapillary Duodenal Diverticula
 Frequently found in elderly patients
 Alter the position and anatomic
boundaries of the papilla and displace
the course of the bile and pancreatic
ducts, making cannulation more
difficult. Juxtapapillary Duodenal Diverticulum

37.  Correction:
1. Aspirating air from the diverticulum
may help “evert” the diverticulum,
bringing the papilla into a more
favorable position for cannulation.
2. Altering patient position and applying
abdominal pressure also may be
helpful.
3. Failing these, a small depot of normal
saline can be injected into the
submucosal plane of the mucosa
adjacent to the papilla. The injection
should be made on the diverticular side
of the papilla in an attempt to “tilt” the
papilla toward the endoscopist.
Cannulation done after injecting saline

38. Billroth II gastrectomy cannulation
 Accessing the papilla is the first
obstacle.
 The afferent loop can be difficult to
intubate, and the papilla can be
difficult to reach when the afferent
loop is long.
 Cannulation of the Billroth II papilla is
the second obstacle.
 Because the endoscope approaches
the papilla from below rather than
above, the papillary anatomy in a
Billroth II patient is reversed.

39.  The bile duct is cannulated by
orienting the catheter
downward at the 5 to 6
o'clock position, rather than
the standard 11 to 12 o'clock
position.
 It is helpful to use a new
straight catheter or mold a
downward bow into the
catheter to achieve this.

40. Sphincterotomy

41. Introduction:
 Aims at opening the terminal part of the
common bile duct or pancreatic duct by
cutting the papilla and sphincter muscles.
 Although not always mandatory for
interventional procedures, it greatly
facilitates ductal access and manipulation.
 The standard sphincterotome (Erlangen
“pull-type” model) consists of a catheter
containing a cautery wire, which is exposed
20 to 25 mm near the tip of the instrument.
 The leading tip distal to the wire (“nose”) is 5
to 10 mm.
Erlangen sphincterotome

42. Procedure:
 After deep bile duct cannulation, the
sphincterotome is retracted slowly until one
fourth to one half of the wire length is exposed
outside the papilla.
 The sphincterotome is slightly bowed so that
the wire is in contact with the roof, but not
excessively to avoid a “zipper” incision.
 The incision is made by gently lifting the
sphincterotome against the papillary roof using
the elevator and up-down controls while
applying short bursts of current.

43.  The length of a bile duct sphincterotomy depends on the indication.
 A small incision (≤1 cm) is adequate for stent insertion, whereas stone
extraction usually requires a larger incision depending on the size of
the stone to be extracted.
 The length of a pancreatic duct sphincterotomy should not exceed
1cm because of the perpendicular insertion at the ampulla.
 The adequacy of a sphincterotomy can be gauged by the ability to
move the bowed sphincterotome across the opening.

44. Special Cases:
 In the presence of a juxtapapillary diverticulum, the incision should
be performed in millimeter increments, paying close attention to the
boundaries of the incision and the course of the intraduodenal
segment of the bile duct.
 In a Billroth II patient, the standard Erlangen-type sphincterotome is
not suited for sphincterotomy because of the reversed anatomy.
 The Soehendra Billroth II sphincterotome is designed to produce an
upside-down bow in the cutting wire so as to orientate the wire
correctly within the bile duct.

45. 1. PS haemorrhage- more while using
pure cutting current
2. PS pancreatitis- more while using
blended current than in pure cutting
The best practice to avoid these complications is
by performing
the first third of the sphincterotomy with the
generator in the cut setting,
the middle third with blended current,
and the final third with coagulation current.
Complications
Duty cycle- refers to the % of total time that electrical
current is actually delivered. This is dependent on the
frequency and duration of any pauses that are
programmed into the cycle
Pure Cut- 100% duty cycle
Coag current- 6% duty cycle
Blended current- preset duty cycles ranging from 12-80%

46. Rationale: The risk of causing pancreatitis is highest during the initial
portion of the Sphincterotomy.
The risk of causing bleeding is highest near the apex of the
sphincterotomy (because of the proximity of the pancreatic orifice and
blood vessels, respectively).
3. Retroperitoneal perforation- that results from an uncontrolled
“zipper-cut”.
can be avoided by ensuring that enough wire is withdrawn from the papilla.

47. Endoscopic procedures for
pancreatic calculi

48. Stone Extraction
 85% of pancreatic stones & approx. 90% of
bile duct stones can be removed effectively
after endoscopic sphincterotomy combined
with the Dormia basket or balloon catheter.
 The choice of basket or balloon is largely
dictated by stone size.
 The Dormia basket is sturdier and provides
better traction for removal of a larger stone.
 The balloon catheter occludes the lumen and
is ideal for removing small stones or sludge.
Dormia basket with large
stone extraction
Balloon catheter with
small stone extraction

49. Points to remember during stone extaction
 Technical points to increase the success rate of stone extraction.
1. Sphincterotomy should be generous enough.
(The adequacy of the incision can be assessed by passing an inflated balloon
catheter through the sphincterotomy opening.)
2. If multiple medium or large stones are present, it is important to
remove stones individually, beginning with the lowermost stone, to
avoid stone impaction.
3. If pancreatic duct stones tend to be firmly impacted or form
proximal to a stricture, a preliminary fragmentation using lithotripsy
techniques would be required.

50.  Standard stone extraction techniques may fail when a stone is large,
impacted, multiple, or proximal to a stricture.
 A variety of modalities are currently available to fragment these
“difficult” stones before extraction, includes
mechanical lithotripsy,
intraductal shock wave lithotripsy,
extracorporeal shock wave lithotripsy, and
dissolution therapy.

51. Mechanical Lithotripsy
A mechanical lithotripter consists of a wire basket, a metal sheath, and a handle,
which provides mechanical retraction of the basket into the metal sheath,
directing a crushing force to the stone.
Through the scope lithotriptor
Used while the endoscope remains in the patient.
Out of scope lithotriptor
Attached to retrieval basket after the endoscope has
been removed.

52. Intraductal Shock wave Lithotripsy
 Intraductal lithotripsy is performed using flexible probes
that can be introduced into the bile or pancreatic duct.
 The shock waves are generated using electrohydraulic
or laser technology and are applied directly to the stone
surface.
(Binmoeller et al, 1993; Cotton et al, 1990; Leung & Chung, 1989;
Siegel et al, 1990)
 Because shock waves can cause injury to the duct wall,
intraductal lithotripsy generally is performed under
endoscopic guidance using a “babyscope” that is
inserted into the duct via the duodenoscope, or
“motherscope”.
 The lithotripsy probe is inserted through the operating
channel of the babyscope, and shock waves are fired
under visual guidance until adequate stone
fragmentation is achieved.
Short Access Minimal Mother
Baby (SAMBA) scope

53. Extracorporeal Shock Wave Lithotripsy
 Extracorporeal shock wave lithotripsy has been shown to be an
effective and safe method to fragment bile and pancreatic duct
stones that defy endoscopic extraction.
 But in a prospective randomized study, extracorporeal shock wave
lithotripsy was found to be less effective than intraductal shock wave
lithotripsy because-
50% of patients require adjunctive treatments to achieve complete
ductal clearance of stone fragments. (Bland et al, 1989)
50% of patients require subsequent stenting for associated strictures.
(Delhaye et al, 1992; Smits et al, 1996b)

54. Stricture Dilation

55. Introduction
 Pancreatic duct strictures is one of the most
common complications of chronic
pancreatitis, sclerosing cholangitis or post-
operative injury (iatrogenic).
 Stricture dilation can be performed using
push-type dilation catheters (bougies) or
high-pressure hydrostatic balloons.
 Balloon dilation is usually used in
conjunction with stent placement to
maintain the dilation effect.(Davids et al, 1992)
High-pressure hydrostatic balloon

56. Procedure
 The balloons are available in varying
lengths (2, 3, and 4 cm) and diameters (4,
6, and 8 mm).
 When inflated, the balloon applies radial
dilating force.
 The balloon is inflated with diluted contrast
material to the maximum atmospheric
pressure allowable and kept inflated until
the stricture “waist” disappears (generally
30-60 seconds of inflation).
 Dilation is painful, and this may limit the
duration of inflation.
 Sequential brief dilations may be better
tolerated.
Stenting done in
pancreatic duct stricture

57. Soehendra Rotational Device
 Used for tight strictures that do not permit
passage of a bougie or balloon
 Has a threaded tip at its end with a central
lumen for coaxial guidewire insertion.
 After placement of a guidewire across the
stricture, the retriever device is coaxially
inserted until it engages the stricture.
 The rotational device is rotated clockwise at
the handle by the assistant, while the
endoscopist advances the device across the
stricture.

58. Stenting

59. Introduction
 Endoscopic transpapillary stent placement is a well-standardized
technique today and can be carried out with an overall success rate of
greater than 90%.
 Stenting has become the treatment of choice for the palliative
decompression of malignant distal biliary obstruction
 It is an accepted alternative to surgery for the treatment of benign
distal biliary and pancreatic strictures.
 Stenting also has been found to be an effective treatment for bile and
pancreatic duct leaks.

60. Types of Stents
1. Plastic, may be-
a. straight, with flaps for
anchorage;
b. single pigtail; or
c. double pigtail
2. Self expandable metal (SEMS),
may be-
a. uncovered; or
b. covered
Plastic stents- Straight, single pigtail, double pigtail
Metal stents- uncovered and covered

61. Plastic Stents Metal Stents
Advantages 1. Cheaper 1. Longer patency (> for
covered)
2. Significantly less stent
occlusion by 4 months
3. Reduced risk of recurrent
biliary obstruction
4. Least chances of stent
migration with
uncovered SEMS
Disadvantages 1. Shorter patency < 3
months
2. High chances of stent
occlusion
3. Overall high incidence of
stent migration
4. Post stenting pancreatitis
1. Costly
2. Higher incidence of stent
migration with covered
SEMS
3. Post stenting pancreatitis

62. Procedure
 A small sphincterotomy is performed to facilitate insertion of further
instruments.
 The stricture is negotiated with a guidewire.
 Special hydrophilic wires allow easier and less traumatic passage
through strictures.
 When stricture is passed with a wire, a dilating catheter is coaxially
inserted to dilate the stricture.
 A stent (plastic or expandable metallic) is inserted using the Seldinger
technique.

63.  Postoperative biliary strictures and
pancreatic strictures secondary to chronic
pancreatitis may require 1 year of stenting.
(Binmoeller et al, 1995; Smits et al, 1996)
 The placement of multiple stents by adding
a stent at 3-month intervals may optimize
the dilation effect.
Multiple stents
placement

64. Peroral Endoscopic
Debridement

65. Introduction
 Used in Necrotising pancreatitis
 Limited to Walled Off N.P
(WOPN)
 Performed via transgastric or
transduodenal approach
When to operate:-
• Wait at least 3 to 4 weeks.
• Waiting for encapsulation or “walling off” is
critical to the success of primary endoscopic
therapy, and often directly correlates with the
degree to which the collection is encapsulated.

66. Procedure
 Areas of pancreatic necrosis identified.
 A transluminal puncture made.
 Guidewire placed into the cavity to facilitate advancement of a large (up
to 20 mm) hydrostatic balloon for dilatation of the gastric wall.
 Once the gastrostomy is established, direct endoscopic debridement
done.
 At the end of the debridement, stents are placed into the cavity.
 A 7-French pigtail nasocystic tube alongside the stents is placed for
postoperative intracavitary lavage.

67. Advantages
1. Low procedure related morbidity
and mortality
2. Less risk of post procedure
pancreatic fistula as internal
drainage is established.
1. Necrosis has to be walled-off and
endoscopically accessible.
(inaccessible -> Rt. & Lt. retroperitoneal
extensions mainly in psoas muscle)
2. Requires repeated procedures
for resolution
3. High risk of local bleeding
complications
Early (<24hrs)- due to avulsed
peripancreatic vessels
Late (>24hrs)- due to rupture
pseudoaneurysm
Disadvantages

68. Endoscopic Pancreatic
Cystenterostomy

69. Introduction
 Management of cystic lesions of the pancreas requires careful, directed diagnostic
evaluation utilizing a multidisciplinary approach.
 It is important to confirm that the cystic lesion is a pseudocyst and not a cystic neoplasm
of the pancreas.
 Pancreatic pseudocyst formation requires
disruption of the pancreatic ductal system
inflammatory reaction of surrounding tissues
That results in formation of a fibrous capsule or wall that lacks an epithelial lining.

70.  Pseudocyst results from fluid collection persisting for more than 4 WEEKS after the
onset of an episode of Acute Pancreatitis (in 5% to 15% of patients) or Chronic
Pancreatitis (>25%).
-Jacobson
 Causes can be-
Isolated injury due to blunt abdominal trauma
Transection of the main pancreatic duct during pancreatic resection
Acute pancreatitis due to alcohol or gallstones
 When to operate:
In symptomatic patients
Those with pseudocysts >6cm
With wall thickness >6mm
That have failed to resolve over a set time interval (6 wks).
(Canine models of pseudocyst formation, 1950; Edward Bradley, 1970)

71. Role of EUS
 Provides invaluable information to rule out cystic neoplasms.
Including
cyst content,
wall nodularity,
Vascularity,
Septations.
 EUS also allows for fine needle aspiration of the cyst cytology.
 Mucin content, viscosity, amylase and carcinoembryonic antigen
(CEA) can help differentiate pseudocysts from cystic neoplasms.

72. Nealon's Classification: Endoscopic Retrograde
Cholangiopancreatography
 Nealon and Walser have demonstrated
the importance of ductal anatomy in the
management of pseudocysts.
 Patients with a normal pancreatic duct
without communication to a pseudocyst
and acute pancreatitis had shorter length
of drainage and hospital stay than
patients with complete cutoff of the duct
(Nealon Type V).
 All patients with chronic pancreatitis
(Nealon Type VI, VII) fail to respond to
percutaneous drainage and ultimately
require surgical intervention.

73.  The choice of treatment (open, percutaneous, or endoscopic) depends on
multiple factors including
size,
number,
location of the cyst,
the presumed absence of infection or residual necrotic tissue,
the presence or absence of a cyst-duct communication,
the availability of specialists in endoscopy.
 Different endoscopic techniques that are used for pseudocyst drainage
are—
1. Transpapillary Drainage
2. Transmural Drainage

74. Transpapillary Drainage

75. Introduction:
 Endoscopic transpapillary drainage is
effective for pseudocyst that
communicate with the pancreatic
duct (Nealon type II).
 In it, an attempt is made to drain the
pseudocyst content into duodenum.

76. Procedure
 A side-viewing duodenoscope is passed up to the level of the ampulla
of Vater.
 Biliary access is obtained by directing the sphincterotome superiorly
and anteriorly in the ampulla toward the 11 o'clock direction.
 Decompression of the pancreatic duct done.
 A stent with appropriate length and a caliber of 7 French is then
passed over the guide wire into the pseudocyst.

77.  The stent remains in the
pancreatic duct until the
pseudocyst resolves or
significantly decreases in
size as demonstrated by
CT.
 Stent removal, re-
evaluation and
replacement usually
occur in 6 to 8 weeks.
Pancreatic Pseudocyst with
insertion of guide wire
PD Balloon Dilatation
PD Stent

78. Transmural Drainage

79. Introduction:
 In this method, a direct cyst-gastrostomy or
duodenostomy is performed.
 For non communicating pseudocyst.
 On examination of the gastric or duodenal
lumen, those patients with pseudocyst
indentation of the enteric lumen are
candidates for transmural drainage.
endoscopic view of bulging pseudocyst
in stomach

80. Procedure:
 A needle knife is used to open the indented area of the enteric
lumen.
 A small area of 3 to 5 mm of mucosa is cauterized and the needle
knife is used to puncture the center of this area.
 Extrusion of cyst fluid is encountered when the cyst is entered and a
guide wire is then passed though the center of the needle knife into
the cavity.
 A sphincterotome can be passed over the wire to enlarge the cyst-
enterostomy.
 A radial expansion balloon can be used to dilate the cystenterostomy
in cases where there is bleeding from the mucosa.
 An opening of a minimum of 1 cm is preferable.

81.  The pseudocyst is drained
with one to two 10 French
stents, side by side.
 Double stenting is more
effective than a single stent
because single stents can be
encased by gastric mucosa
and induce infection when
their lumen becomes
occluded.
Initial use of cautery to enter
into the pseudocyst
Guide wire placed through cyst gastrostomy Gastric view of stents

82. Ampullectomy

83. Introduction
 Adenomas of the major duodenal
papilla, also k/a ampullary adenomas,
can occur sporadically or in the context
of genetic syndromes such as familial
adenomatous polyposis (FAP).
 These lesions have the potential to
undergo malignant transformation to
ampullary carcinoma.
Ampullary adenomas

84.  Surgical management often allows
complete removal but carries
morbidity, including anastomotic
dehiscence (9%) and fistulae
(14%).
 Endoscopic approaches for the
evaluation and treatment of
ampullary adenomas now
represent a viable alternative to
surgical therapy. Endoscopic view of ampullary adenoma

85. Role of EUS
 EUS and intraductal US (IDUS) have emerged as useful techniques to
assess the depth of involvement in patients with ampullary neoplasms.
 These modalities allow
assessment and extent of intraductal extension
extension beyond the muscularis propria
evaluation of periampullary lymph nodes in patients suspected of
carcinoma.
 Lesions less than 1 cm in diameter or those that do not have suspicious
signs of malignancy (ulceration, induration, bleeding) do not require
ultrasonographic evaluation before endoscopic removal.

86. Procedure
 In this technique snaring of the papilla with
the duodenal wall is done.
 Special diathermic snare are available.
 Before endoscopic papillectomy is
performed, it is important to inject saline in
the sub mucosa.
 Failure of a lesion to manifest a ‘‘lift sign’’ is
associated with malignancy and is
considered a contraindication to attempts at
complete endoscopic resection.
Diathermy snare

87.  If the lesion can be completely ensnared, en
bloc resection with electrocautery can be
performed.
 Piecemeal resection (with electrocautery) is
often performed for lesions larger than 2 cm
or in cases where an attempt at en bloc
resection has left visible neoplastic tissue in
place.
 Surgical resection is indicated if the specimen
shows malignancy, or complete excision
cannot be achieved endoscopically.
 Periodic endoscopic surveillance is mandatory
to evaluate for adenoma recurrence.

88. Endoscopic Surveillance
Initial surveillance examination- 1 to 6 months after the index
procedure.
Followed by repeat examinations with a duodenoscope every 3
months thereafter for a period of at least 2 years.

89. References
• Grant’s Atlas of Anatomy, 13th Ed.
• Sobotta’s Atlas of Anatomy, 15th Ed.
• Skandalakis Surgical Anatomy
• Love and Bailey Textbook of Surgery, 26th Ed.
• Fischer’s Master of Surgery, 6th Ed.
• Blumgart: Surgery of the Liver, Biliary Tract and Pancreas, 4th Ed.
• Schwartz Principles of Surgery, 10th Ed.
• Internet