Change to ideal GIT center with minimal invasive technique بسم الله الرحمن الرحيم Change to ideal GIT center with minimal invasive technique Aswad Alobeidy

Changes Liver biopsy to Fibroscan. Common bile duct exploration Vs Spyglass. FNA with multiple sampl. to immediate histopathology. Pancreatic pseudocyst surgery Vs Endoscopic necrosectomy. Necrotizing Pancreatitis surgery Vs Percutaneous necrosectomy.

Needs to change Low morbidity and complications. Short hospitalization. Minimum coast. Rapid diagnosis and intervention. Better outcome and prognosis.

Stakeholders MOH Some doctors power Patients Population Nurses 4 Surgeon 2 PB physician PB Radiologist Interventional radiologists Intensivists Pathologist MOH Some doctors power Patients Population Nurses Interest

Fibroscan A painless alternative to liver biopsy for evaluating the stage of liver fibrosis A mechanical pulse is generated at the skin surface, which is propagated through the liver. The velocity of the wave is measured by ultrasound. The velocity is directly correlated to the stiffness of the liver, which in turn reflects the degree of fibrosis metabolic syndrome and non-alcoholic fatty liver disease, chronic viral hepatitis and excess alcohol intake. can monitor the progression, regression of liver disease and the success of treatments or lifestyle modification.

Fibroscan FibroTest and FibroScan have excellent utility for the identification of HCV-related cirrhosis, but lesser accuracy for earlier stages. Refinements are necessary before these tests can replace liver biopsy (1) in patients with chronic HCV hepatitis, liver stiffness measurement could be used for the decision of therapy, in most patients, avoiding LB. (2) 1. Am J Gastroenterol. 2007 Nov;102(11):2589-600. Epub 2007 Sep 10 2. Sporea I ,et al,World J Gastroenterol 2008; 14(42): 6513-6517.

Spyglass Visualise biliary system. Biopsy taken. Electro hydraulic or Laser lithotripsy of difficult CBD stones Procedure started at 16th June 2008

SpyGlass™ Direct Visualisation System SpyScope™ 10Fr Access & Delivery Catheter Monitor Camera Light Source Pump Cart 3-joint Arm Isolation Transformer ERBE Irrigation SpyGlass ™ Fiber Optic Probe SpyBite ™ Biopsy Forceps

Conclusion Spyglass offers a potentially cost effective way to More accurately diagnose undetermined biliary strictures by maintaining high sensitivity and a high NPV. The combination and appropriate sequencing of CT, EUS, ERCP and Spyglass should improve the management of biliary strictures. Non operative management of large CBD stones that have failed conventional lithotripsy.

FNA with multiple sampl. to immediate histopathology Newly developed technique like FFB. The aim is to decrease the number of the sampling. Immediate diagnosis and rapid intervention Short procedure time. Coast effective.

Rationale for minimally invasive necrosectomy Definitive procedure - in patients with co-morbidity, e.g. high BMI, advanced age, multiple organ failure Bridging procedure - to improve the patient’s condition and postpone the open procedure until resolution of organ failure Open necrosectomy is associated with high mortality and morbidity Infected necrosis is often walled off and applied to posterior wall of stomach Percutaneous access may not always be possible particularly in necrosis of the head

Minimal access techniques Percutaneous necrosectomy Laparoscopic necrosectomy Endoscopic necrosectomy

Steps in endoscopic necrosectomy EUS guided puncture to access the cavity Majority of procedures performed entirely with therapeutic linear scope Currently use Cystotome ( Wilson-Cook) Dilatation of opening over a wire Removal of solid and liquid material Stents to keep cavity open Nasocavity irrigation if necessary Cavity endoscopy sometimes possible

Endoscopic necrosectomy for Infected Necrosis May 2002-Oct 2004 Attempted on 13 patients with walled off necrosis via trans gastric approach. 11(84%) positive bacteriology Patients identified on the basis of clinical/CT criteria All patients had EUS prior to drainage, in the majority the entire initial procedure performed with echoendoscope Nasocavity drainage if deemed necessary 2 patients had general anaesthesia (on 3 occasions) Charnley R et al. Endoscopy 2006 Sept; 38(9):925-8

Risk High coast e.g Fibroscan Not useful in all patients Prolonged procedure initially Good training Complications e.g endoscopic necrosectomy

Conclusion Extensive necrosis can be successfully treated with a minimal access technique or combination of techniques Endoscopic necrosectomy can be effective even in the presence of infection Multidisciplinary team input is vital Labour intensive pastime: Input required for 1 case Surgeon - Percutaneous necrosectomy (4) Gastroenterologist - EUS (1) /ERCP (1) / OGD (2) Intensivist - 54 days Microbiologist - 8 pathogens / 11 sites / 9 therapies Radiologist - CT (7), CT drain (2), USS (6), Angiography (3) Ward staff - 64 days

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