Endoscopic Management of Pancreatic Fluid Collection in Acute Pancreatitis
By Cosmas Rinaldi Adithya Lesmana, Laurentius Adrianto Lesmana and Khek Yu Ho
Acute pancreatitis is an acute clinical condition where it can be manifested as mild disease or serious and life-threatening condition. There are several factors that may be responsible for this condition, such as genetic, gallstone disease, alcohol consumption, pancreatic trauma, medication, hypertriglyceridemia, autoimmune disease, and surgery. The most common manifestation of pancreatic parenchymal injury is pancreatic pseudocyst (PPC) formation, where peripancreatic fluid collection (PFCs) usually precedes this condition. Even though most of the pseudocyst can be managed conservatively, however in conditions such as infected pseudocyst or possible wall of necrosis (WON), there should be an early intervention management. Clinical evaluation and imaging studies have to be done in the beginning. Computed tomography (CT) scan or magnetic resonance imaging (MRI) are the main imaging techniques used to evaluate the characteristic of the cyst, the size, surrounding vascularity, and to assess the pancreatic duct itself with possible of fistula formation. Clinical conditions that are usually considered for early intervention management are symptomatic pseudocyst, large size of pseudocyst, presence of gastric outlet obstruction, or biliary obstruction. PFC should be evaluated as it has been classified based on type of pancreatitis, time frame, well-defined wall, and debris contained inside the cyst. Endoscopic management has replaced percutaneous and surgical approach in most of PFC cases. Nowadays, endoscopic ultrasound (EUS) has been widely used as the first-line tool for PFC drainage procedure. Pancreatic pseudocyst stenting is the most common procedure in most of the centers in the world. However, the cost, availability, and expertise are needed to be considered in clinical practice.
Part of the book: Pancreatitis
The New Era of Immunotherapy in Bile Duct Cancer Management
By Cosmas Rinaldi Adithya Lesmana and Baiq Kirana D. Mandasari
Bile duct carcinoma or well known as cholangiocarcinoma (CCA) is the second most common of primary liver malignancy after hepatocellular carcinoma (HCC). Although cholangiocarcinoma is a rare cancer, it has an aggressive feature with very poor prognosis. The epidemiological profile of cholangiocarcinoma varies widely across the world, which is reflecting the exposure of different risk factors, such as chronic inflammatory disease of the biliary tract, specific infectious disease, and congenital malformation. Diagnosis of CCA is quite challenging. CCA is generally asymptomatic in the early stages. Therefore, the management of this malignancy is often delayed due to late diagnosed, where the metastasis has already present or even when it is causing bile duct obstruction. Treatment for CCA is often difficult and should be managed in the tertiary referral hospital with a multidisciplinary team approach. Surgical treatment with complete resection could be benefit only for patient with early stage of the disease. Other treatment modalities as adjuvant therapy are also have been developed to improve survival of the patient, such as chemotherapy, radiotherapy, molecular targeted therapy, targeting angiogenesis and EGFR, and immunotherapy. Recently, immunotherapy has also been developed as a new cancer treatment option and showed a promising result. Whether immunotherapy can be useful for treatment biliary malignancy is still controversial. Hence, a lot of studies is still required to confirm the preliminary findings.
Part of the book: Immunosuppression
The Role of Endoscopic Ultrasound in Acute Cholecystitis
By Cosmas Rinaldi A. Lesmana and Laurentius A. Lesmana
Acute cholecystitis (AC) is one of challenging clinical conditions in biliary disorders as it can carry high morbidity and mortality. Gallstone disease is still the main cause of AC in clinical practice. Transabdominal ultrasound, abdominal CT scan and abdominal MRI are the standard diagnostic tools in AC, however, some obstacles can be found which are associated to the patient’s factor, anatomy or anomaly of biliary system, the disease severity, and the operator. Cholecystectomy is still the primary choice management in AC condition, however, several issues need to be encountered, such as critically ill condition, sepsis, and patient’s comorbidity. Percutaneous approach has become an alternative as it is considered as a simple procedure to be performed in clinical practice. Catheter dislodgement, the risk of bile leakage, and uncooperative patients have raised major concerns for this procedure. Another method, such as endoscopic approach has been studied as well and it seemed to have more advantage when compared to the percutaneous approach. Recently, endoscopic ultrasound (EUS) has been used as a combined diagnostic as well as therapeutic tools in managing biliary disorders. Recent evidences about the role of EUS approach for gallbladder drainage (EUS GBD) in patients who unsuitable for surgery have emerged in the past one decade. However, comprehensive evaluation before which approach is the best option is needed as expertise, cost, and patient’s outcome prediction are the most important factors to be considered in the real clinical practice.
Part of the book: Gallstones