Su1400 EUS-GUIDED HEPATICOENTEROSTOMY: A SINGLE CENTER U.S. EXPERIENCE IN A COHORT WITH PRIMARILY BENIGN DISEASE AND ALTERED SURGICAL ANATOMY

Abstract

Endoscopic ultrasound-guided hepaticoenterostomy (EUS-HE) is typically used to treat malignant biliary obstruction when conventional ERCP fails. Limited data exist on use of EUS-HE for benign biliary obstruction. Describe outcome of EUS-HE using a fully covered biliary non-foreshortening self-expandable metal stent (FCSEMS) and assess patient and procedural characteristics on technical success. Retrospective review of 35 consecutive patients considered for EUS-HE performed by one endoscopist from 1/2015 - 11/2017. 35 patients were considered for EUS-HE. 27 had surgically-altered anatomy; 20 Roux-en-Y (16 gastric bypass, 4 hepaticojejunostomy), 2 Billroth II, 1 gastrojejunostomy, 3 Whipple and 1 other. 23 were outpatients at time of EUS-HE. 3 were excluded due to lack of intrahepatic ductal dilation on EUS. Of 32 patients undergoing EUS-HE, 21 were female, (median age 68 years) and only 7 (22%) had malignant biliary obstruction. General anesthesia was used for all cases. EUS-HE was technically successful in 25 patients (78%). In 7 failed EUS-HE there was lack of intrahepatic ductal dilation; 5 underwent balloon-assisted ERCP, 1 underwent surgery and 1 was observed. In the 25 technically successful cases stent(s) were deployed into the left hepatic duct; electrocautery was only used in 4 patients; the tract was dilated via tapered catheters and biliary balloon dilators (mean diameter 4.3 mm) followed by placement of a FCSEMS (VIABIL® Biliary Endoprosthesis, W.L. Gore & Associates). Stent diameters were: 8 mm (N=18) or 10 mm (N=7). Lengths were 40 mm (N=1), 60 mm (N=3), 80 mm (N=16), and 100 mm (N=5); plastic stents were variably placed through the SEMS. The average duct diameter in technically successful HE was 9.4 mm vs 1.4 mm when failed (p=0.001). In 17 patients antegrade ERCP (mean procedures 3.1) was subsequently performed via HE for stone clearance and downstream stricture treatment (6 benign anastomotic, 1 malignant hilar). Stone clearance was achieved in all using balloon sphincteroplasty, cholangioscopy and antegrade sweeping. One severe adverse event (perforation) occurred at a site remote from the HE, surgically managed. 18/23 remained outpatient. Mean inpatient hospital stay was 1.6 days. EUS-HG stents were removed in 15 patients at a mean duration of 86 days, without adverse events. 3 deaths during the follow-up period were due to underlying malignancy. EUS-HE using a commercially available, fully covered self-expandable biliary stent is safe and effective in managing benign and malignant biliary obstruction in patients with otherwise inaccessible biliary anatomy. Left hepatic ductal diameter > 5 mm was a statistically significant predictor of technical success. Studies are needed to determine optimal patient selection and procedural technique.