Su1264 EUS-GUIDED HEPATICOGASTROSTOMY AS SALVAGE TREATMENT FOR ACUTE CHOLANGITIS SECONDARY TO HILAR MALIGNANT OBSTRUCTION

Abstract

Unresectable malignant hilar biliary obstruction (MHBO) often cause complicated biliary obstruction requiring a challenging endoscopic biliary drainage. Endoscopic transpapillary stenting using multiple metal stent has been recently reported with high technical and clinical success. However, reintervention with transpapillary endoscopic stenting often encounters technical difficulty in selective intrahepatic biliary cannulation when acute cholangitis occurs in the segmental bile duct beyond the indwelling trasnpaillary metal stents or the severe biliary stricture. EUS-guided hepaticogastrostomy (EUS-HGS) potentially provides effective isolated biliary drainage for MHBO as a therapeutic option. In this study, we evaluated the safety and feasibility of EUS-HGS for acute cholangitis in the segmental bile duct in MHBO patients. We retrospectively investigated the clinical outcome of EUS-HGS in acute cholangitis for MHBO after transpappilary endoscopic approach were failed or supposed to be challenging between April 2015 and Octorber 2019. Technical success rate, the details of the procedure, clinical success rate (resolution of acute cholangitis and reintroduction of chemotherapy), and procedural complications were evaluated. A total of 32 patients were underwent EUS-HGS for MHBO during our study period. Technical success rate was 90.6% (n=29). In technical success 29 patients, 21 were men; the median age was 70 (range from 25 to 94 years old). The puncture sites of the intrahepatic bile duct were B2 (52%), B3 (41%) and B6 (7%). The cancer primary was hilar cholangiocarcinoma (34%), gallbladder cancer (24%), intrahepatic cholangiocarcinoma (17%), pancreatic cancer (17%), and other cancers (17%). ECOG performance status (PS) before EUS-HGS was PS 0, 17%; PS 1, 58%; PS 2, 17%; PS 3, 7%; and PS 4, 0%. Cholangitis severity before EUS-HGS was Grade 1 (mild), 38%; Grade 2 (moderate), 62%; Grade 3 (severe), 0%, based on the criterion of Tokyo Guidelines 2018 (TG18). The stents for EUS-HGS were plastic (83%) and metal (17%). Resolution rate of cholangitis was 89%, and reintroduction rate of chemotherapy was 68%. In better performance status (PS 0-1) or milder acute cholangitis by TG18 evaluation criteria, chemotherapy-resume rate were favorable, compared to poor PS (PS 2-4) (88% vs. 58%, p = 0.06) or more severe acute cholangitis (53% vs. 16%, p = 0.04), in any stent types nor drainage route. Complication rate was observed in 4 cases (13%); 2 abdominal emphysema and 2 liver abscess as late complications. All the adverse events were conservatively managed. In our study, EUS-HGS showed a safe and feasible drainage approach for acute segmental isolated cholangitis in MHBO, when endoscopic trasnpapillary approach failed or became difficult.