Su1381 EUS-Guided Gallbladder Drainage As an Alternative Treatment for Malignant Biliary Obstruction After Unsuccessful ERCP: Outcomes of Long Term Follow-Up

Abstract

Su1381 EUS-Guided Gallbladder Drainage As an Alternative Treatment for Malignant Biliary Obstruction After Unsuccessful ERCP: Outcomes of Long Term Follow-Up Masayuki Kitano, Hajime Imai, Ken Kamata, Takamitsu Komaki, Hiroki Sakamoto, Masatoshi Kudo Department of Gastroenterology and Hepatology, Kinki University, Osaka-sayama, Japan Background and Aims: Transpapillary biliary drainage is sometimes difficult due to severe biliary stricture, duodenal stenosis and surgically altered anatomy. EUSguided drainage has been recognized as an alternative method enabling the internal drainage. Recently, EUS-guided gallbladder drainage (EUS-GBD) was reported as a treatment of decompression for acute cholecystitis. We employed the new technique as an alternative treatment for malignant obstructive jaundice and assessed its outcomes of long term follow-up. Patients and Methods: A total of 10 patients underwent EUS-GBD for treatment of acute cholecystitis due to obstruction of cystic duct by a covered metal stent (CMS) (n 5) and obstructive jaundice due to malignant biliary stricture (n 5). In 5 patients with obstructive jaundice, transpapillary drainage had been unsuccessful, and EUS revealed that the cystic duct was not involved by the tumor. A linear echoendoscope was introduced into the stomach or the duodenum. Following visualization of a swollen gallbladder adjacent to the gastric antrum or the duodenal bulb, the echoendoscope was manipulated in order to identify an appropriate puncture route that has no interposing vessels. The gallbladder was punctured with a 19G needle under the enodsonographic guidance. After the gallbladder is irrigated by a large amount of saline ( 500mL) to avoid the peritonitis by leakage of the bile, a 0.025-inch guide wire is introduced until it was coiled within the gallbladder, and then 5.5-9-Fr catheters were serially advanced over the guide wire to dilate the tract. Finally, a 7-Fr. pigtail-type stent was deployed in the gallbladder. The technical success, the functional success, the complications and the stent patency were assessed. Results: The gallbladder was successfully punctured by the needle and irrigated in all patients. The needle was punctured from the stomach and the duodenum in 7 and 3 patients, respectively. However, dilation of the punctured hole was difficult in 2 of 5 patients with acute cholecystitis caused by the CMS due to thickening of the gallbladder wall. Consequently, these 2 patients were followed up after a single aspiration and irrigation. The remaining 8 patients underwent deployment of a stent after successful dilation of the punctured hole. The symptoms were relieved in all patients. Two weeks after the procedure, the bilirubin level was decreased in the 5 patients with obstructive jaundice. No apparent complications such as peritonitis and bleeding occurred in all patients. The median survival time was 134 days (range51-236 days). No additional intervention was needed in 9 patients except a patient treated with a single aspiration of the gallbladder. Conclusion: EUS-guided gallbladder drainage is a possible alternative treatment of decompression in the biliary system when the transpapillary drainage is unsuccessful.