924 How Successful Is Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction Post-Pancreaticoduodenectomy?

Abstract

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is the accepted therapy for the management of biliary obstructions, however, in patients who have had previous pancreaticoduodenectomy (PD) (i.e. Whipple’s procedure), due to the altered surgical anatomy, the ability to perform ERCP is challenging. In this study, we examine our experience at a large tertiary cancer-center in performing ERCPs for biliary obstructions in patients who are post-PD. METHODS: This was a retrospective review from 2006 to 2018 of all patients referred for the management of biliary obstructions post-PD. Outcomes included technical success (ability to treat the stricture, e.g. dilation or placement of a stent) and clinical success (decrease in bilirubin to normal or 50% of peak value within 2 weeks) rates. RESULTS: A total of 66 patients were included in the study. The mean age was 67.7 years (SD +/- 11.6) and 58 patients (87.9%) were male. The most common indications for PD were duodenal adenocarcinoma (20 patients, 30.3%) followed by pancreatic adenocarcinoma (16, 24.4%). In terms of surgery, the mean length of the afferent limb was 45.7 cm (SD +/- 6.34). The most common indications for ERCP were cholangitis (31 patients, 49%), followed by a biliary obstruction without cholangitis (11, 16.7%). The mean length of procedure was 66.7 minutes (SD +/- 34.8). The hepaticojejunostomy (and/or choledochojejunostomy) was reached in 56 patients (84.8%). The most common endoscope used was a therapeutic upper endoscope (31 patients, 47%), followed by a regular upper endoscope (11, 16.7%) and a pediatric colonoscope (10, 15.2%). Cannulation of the biliary tree was successful in 55 patients (83.3%). The most common location for the stricture was at the anastomosis (41 patients, 80.4%), followed by distal extra-hepatic (8, 15.7%). Successful stents were placed in 31 patients (47%). There were no episodes of bleeding, perforation or pancreatitis post-ERCP. Four patients developed self-resolving fever post-procedure. The technical success rate was 75.8% (50 patients) while the clinical success rate was 71.2% (47 patients). CONCLUSION: ERCP post-PD can be challenging due to the surgical anatomy and inability to use common endoscopes and instruments. Our study demonstrates that nevertheless, endoscopic biliary decompression can still be successful by experienced endoscopists in the majority of patients post-PD, with minimal adverse events.