Presentation on theme: "Change to ideal GIT center with minimal invasive technique"— Presentation transcript:
1 Change to ideal GIT center with minimal invasive technique بسم الله الرحمن الرحيمChange to ideal GIT center with minimal invasive techniqueAswad 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 Surgeon2 PB physicianPB RadiologistInterventional radiologistsIntensivistsPathologistMOHSome doctorspowerPatientsPopulationNursesInterest
5 FibroscanA painless alternative to liver biopsy for evaluating the stage of liver fibrosisA 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 fibrosismetabolic 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 FibroscanFibroTest 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 102. 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 stonesProcedure started at 16th June 2008
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 interventionShort 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 failureBridging procedure - to improve the patient’s condition and postpone the open procedure until resolution of organ failureOpen necrosectomy is associated with high mortality and morbidityInfected necrosis is often walled off and applied to posterior wall of stomachPercutaneous access may not always be possible particularly in necrosis of the head
13 Steps in endoscopic necrosectomy EUS guided puncture to access the cavityMajority of procedures performed entirely with therapeutic linear scopeCurrently use Cystotome ( Wilson-Cook)Dilatation of opening over a wireRemoval of solid and liquid materialStents to keep cavity openNasocavity irrigation if necessaryCavity endoscopy sometimes possible
14 Endoscopic necrosectomy for Infected Necrosis May 2002-Oct 2004Attempted on 13 patients with walled off necrosis via trans gastric approach. 11(84%) positive bacteriologyPatients identified on the basis of clinical/CT criteriaAll patients had EUS prior to drainage, in the majority the entire initial procedure performed with echoendoscopeNasocavity drainage if deemed necessary2 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 initiallyGood trainingComplications e.g endoscopic necrosectomy
16 ConclusionExtensive necrosis can be successfully treated with a minimal access technique or combination of techniquesEndoscopic necrosectomy can be effective even in the presence of infectionMultidisciplinary team input is vitalLabour intensive pastime: Input required for 1 caseSurgeon - Percutaneous necrosectomy (4)Gastroenterologist - EUS (1) /ERCP (1) / OGD (2)Intensivist - 54 daysMicrobiologist - 8 pathogens / 11 sites / 9 therapiesRadiologist - CT (7), CT drain (2), USS (6), Angiography (3)Ward staff - 64 days