Su1432 A COMPLETE ASSESSMENT OF THE ROLE OF EUS-GUIDANCE FOR BILIARY AND PANCREATIC DUCT ACCESS AND DRAINAGE

Abstract

EUS-guided ductal access & drainage (EUS-D) of biliary (EUS-BD) or pancreatic duct (EUS-PD) has been used for 20 years. The need for EUS-BD is estimated at 3 in 1000 ERCPs (Holt, GIE-2016), excluding EUS-PD and prior biliary interventions. A complete assessment of the role of EUS-D requires considering the full spectrum of ERCP failure beyond failed cannulation, all patient populations & all indications. Data on concurrent institutional use of PTBD is required to interpret findings. Prospective cohort study at tertiary center including consecutive duct drainage procedures performed June2013-Nov2015. ERCP was used first-line & EUS-D as salvage. Direct EUS-D was selectively used in failed outside ERCP. Referral was stratified as primary (no ERCP), secondary (<200 ERCPs/year) or tertiary (>200 ERCPs/year & IR). Main outcomes: rates of procedural ERCP failure and EUS-D. Total number of PTBD during study period was recorded. Procedures were classified as follow-up or index if patients had prior endoscopic duct access or not. Follow-up procedures included ERCP, EUS-D, endoscopic transluminal cholangio-pancreatography (ETCP) through mature transmural duct fistulas, and combined (ERCP with any antegrade approach [EUS-D or ETCP]). 1625 patients (median age: 74.5 [IQR: 63.5-83.5] 56.3% males) underwent 2205 procedures (median 1 procedure/patient IQR: 1-2), 1274 index and 931 follow-up. Index procedures: 76.7% primary, 17.9% secondary and 5.4% tertiary referrals. Diagnoses: 36.9% CBD stones, 25.8% malignancy, 6.2% benign strictures. 67 patients had surgically altered anatomy (24 Roux-en-Y GJ; 11 B-2, 8 Whipple, 8 Roux-en-Y HJ, 16 Other). EUS-D was performed directly in 45/1274 (3.5%); 30/67 [44.8%] surgically altered anatomy & 15/1207 [1.2%] native anatomy. EUS-D was performed after ERCP in 71/1229 (5.8%); 53 failed cannulation & 18 incomplete drainage despite successful ERCP. Rate of EUS-D at index procedure differed between primary (4.3%), secondary (9%) and tertiary (20%) referrals (p<0.001) Follow-up procedures summarized in Table 1. ETCPs, EUS-Ds and combined procedures accounted for 133 (14.3%) of all follow-up procedures, peaking to 53/211 (25.1%) in malignant strictures. During the study period the total number of PTBDs was 9 (3 after failed ERCP/EUS-D [all in altered anatomy] and 6 direct PTBD). 42 Index EUS-BD procedures resulting from failed cannulation represent (27.5%) of the total 153 EUS-D performed during the study period. After index EUS-D, an additional 96 ETCP or combined procedures allowed non-EUS guided ductal therapy (10.3% of follow-up procedures). EUS-D was performed overall in 6.9% of 2205 biliary and pancreatic duct drainage procedures (7.6% referred from high ERCP volume centers), whereas PTBD was only required in 0.1%. EUS-D can be integrated with ERCP at index and follow-up procedures.Tabled 1Table 1: Types of secondary procedures according to the patients’ diagnosesERCP, nETCP, nEUS-D, nCombined procedures, nBile duct stones1781542Benign strictures23023410Malign strictures15822229Pancreatic procedures14210Other218766Total798693727 Open table in a new tab