Su1327 ENDOSCOPIC ULTRASOUND GUIDED CHOLEDOCHODUODENOSTOMY IS A DURABLE, SAFE AND SUCCESSFUL PROCEDURE IN MALIGNANT BILIARY OBSTRUCTION

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is the standard therapy for palliation of malignant biliary obstruction (MBO). In cases of failed ERCP, patients can undergo either percutaneous transhepatic cholangiography (PTC) drainage or endoscopic ultrasound-guided drainage, including choledochoduodenostomy (EUS-CD). The aim of this study is to compare PTC drainage to EUS-CD in patients with malignant biliary obstruction and failed ERCP. We performed a retrospective cohort study of patients with MBO and failed ERCP identified at Mayo Clinic Rochester from the 2014-2019. Patients with benign biliary obstruction or altered anatomy were excluded. Primary outcomes were technical and clinical success (bilirubin decrease of at least by 50% at 1 week). Secondary outcomes were adverse events (AEs), need for reintervention and survival. Cox regression analysis was used to compare time to reintervention and survival. A total of 36 patients (26 PTC, 13 CD) with malignant biliary obstruction who failed ERCP were included. There were no significant differences between the groups (Table 1). The causes of MBO were pancreatic adenocarcinoma 22 (61.1%), gastroduodenal adenocarcinoma 6 (16.7%), metastatic disease 5 (13.9%), cholangiocarcinoma 2 (5.5%) and myxoid sarcoma 1 (2.8%). Duodenal stricture preventing access to the major papilla was the main cause for failed ERCP in 17 patients (47.2%). Lumen apposing metal stents were used for CD in 9 patients (69.2%). A 10 Fr catheter was used for initial PTC for all patients in the PTS group. Technical and clinical success was 95.6% and 77.3% in the PTC group and 100% and 92.3% in the CD group, P=0.45 and P=0.25. There was one stent maldeplolyment in the CD group which was managed immediately with re-stenting and no immediate AE in the PTC group. Long term AEs were fewer in the CD group (0%) compared to the PTC group (7; 30.4%, P=0.01). The most common AE in the PTC group was clinically significant catheter occlusion in 5 patients (21.7%). 14 patients (60.9%) with PTC required reintervention compared to 0 (0%) after CD, P<0.001. Half of the reinterventions after PTC (7) were elective tube exchanges. There was no significant difference in survival between the two groups HR: 0.75 (95% CI: 0.3 -1.8, P=0.5). EUS-CD is a technically and clinically highly successful procedure without an increased risk for AEs in malignant biliary obstruction after failed ERCP. EUS-CD reduces reinterventions, which enhances end of life quality in patients with advanced malignancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)