World Congress of Gastroenterology

WCOG 2019


 
DIRECT IMAGE-GUIDED RETROPERITONEAL APPROACH AND TREATMENT TO THE PANCREAS USING NOTES AND ENDOSCOPIC ULTRASOUND (EUS).
SOSA-VALENCIA LEONARDO 1 SWASNTRĂ–M LEE 1 AVEROUS GERLINDE 1

1- INSTITUTE OF IMAGE GUIDED SURGERY-IHU, STRASBOURG FRANCE
 
Abstract:

The pancreas is difficult to access surgically. EUS can access it with needle based accessories. EUS large biopsies, lesion resection and distal pancreatectomy could provide clinical advantages. Aim: We propose a hybrid intervention combining a NOTES approach and EUS pre-treatment with intraoperative guidance from a trans-gastric approach. Description: In 4 adult pigs (3 acute and 1 survival), after general anaesthesia, contrast CT scan and pancreatic EUS with Doppler/Elastography was performed. First Procedure (time= 62’’): 1)body-tail localization,2)introduction of a fiducial marker, 3)miniembolization of intra pancreatic vessels around the fiducial using HEA, 4)right and the left radiofrequency(RF) ablation. 5) placement of 2 clips on the gastric mucosa overlying the lesion. All pigs were survived for 4 days with antibiotics, AINES, enteral liquids nutrition and analgesics. Second procedure (mean time=94’’) under general anaesthesia and CO2 insufflation. EUS identified the targeted area and an India ink tattoo was placed. Using an upper endoscope fitted with a cap, and starting 2 cm proximal to the E-G junction a 3 cm long submucosal tunnel was made before exiting the scope through the gastric muscularis and into the retroperitoneal space. Using spray coagulation, a 6 cm tunnel to the pancreas was made. Once at the pancreas, progressive dissection of the pancreatic tail was made to identify the target lesion. Pancreatic biopsies using a jumbo biopsy forceps and small pancreatic resection with a 2.5x5.5 cm polypectomy snare were performed.  The oesophagus was closed with endoscopic clips. Three animals were sacrificed and their pancreas harvested for pathologic examination. One pig was followed for 4 days (same treatment). Return to OR for contras CT and MRI with euthanasia and distal pancreatectomy afterwards. Preliminary Results: No pancreatitis or pain during the survival. All cases of EUS embolization-ablation were satisfactory, endoscopic retroperitoneal tunnelling/targeting was satisfactory in one case. Ablated areas varied from 5-7 cm, 1 had a 2 cc  clear liquid cyst. Normal surrounding parenchyma and pancreatic ducts in the head, and right pancreas body were found. Conclusion: EUS assisted Endoscopic direct retro-gastric access to the pancreas is possible. EUS pancreatic ablation and endoscopic pancreatic partial resect ion in combination are possible.

Keywords:

 NOTES, Endoscopic ultrasound, radiofrecuency ablation, pancreas