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

2. 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.

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

4. 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

5. 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.

6. 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 Nov;102(11): Epub 2007 Sep 10
2. Sporea I ,et al,World J Gastroenterol 2008; 14(42):

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

8. 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

9. 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.

10. 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.

11. 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

12. Minimal access techniques
Percutaneous necrosectomy
Laparoscopic necrosectomy
Endoscopic necrosectomy

13. 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

14. 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

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

16. 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

17. Thank you