Su1565 EUS-Guided Choledochoduodenostomy or Hepaticogastrostomy to Malignant Distal Biliary Obstruction: a Prospective Comparative Trial

Abstract

Su1565 EUS-Guided Choledochoduodenostomy or Hepaticogastrostomy to Malignant Distal Biliary Obstruction: a Prospective Comparative Trial Fernando Marson*, Paulo Sakai, Kiyoshi Hashiba, Everson L. Artifon Surgery Department, University of Sao Paulo Introduction: EUS-guided access to the bile duct is a novel technique that allows biliary drainage when standard ERCP is not feasible. When rendezvous procedure and/or anterograde interventions cannot be done as primary options, the alternative of creating a new fistula, a choledochoduodenostomy or hepaticogastrostomy can still be performed in selected patients. Aim: To compare the outcomes of two different drainage routes: choledochoduodenostomy and hepaticogastrostomy in selected patients that failed ERCP, rendezvous and anterograde intervention with distal malignant obstruction. Patients and Methods: Between April-2010 and July 2012 32 consecutive patients were elected to receive either a EUS-guided choledochoduodenostomy or EUS-guided hepaticogastrostomy. All patients had distal unresectable malignant biliary obstruction and had failed standard ERCP and EUS-guided rendezvous or anterograde intervention. Data including indications, success rate, technique, complications with a 3 month follow-up were prospectively collected in a database. All procedures were performed in a tertiary Endoscopic Unit. A partially covered SEMS (Boston Scientific, Wallflex,10 mm, 6 cm) was used in all procedures. After a EUS-guided bile duct puncture (choledochoduodenostomy) or a EUS-guided left hepatic duct puncture (hepaticogastrostomy) a cholangiogram was obtained followed by advancement of a 0,035 inch guide wire. Track dilation to allow passage of the stent delivery system was performed using a wire-guided needle-knife and bougies. Results: Thirty-two cases (15 hepaticojejunostomies and 17 choledochoduodenostomies) were performed. Indications for the procedure were pancreatic cancer (20 pts), extrinsic compression from metastasis (06) papillary tumor (02), neuroendocrine tumor (02), gallbladder cancer (01) and duodenal cancer (01). All patients were jaundiced and had both intra and extra-hepatic biliary dilation with elevated LFT‘s. Mean procedure time was 47 min. Three patients (2 choledochoduodenostomies and 1 hepaticojejunostomy) failed biliary drainage due to inability to advance the stent and were referred to surgery. Procedure success rate were similar in both groups: 93% for hepaticojejunostomy and 88% for choledochoduodenostomy. Immediate post-procedure complications occurred in 13% of the hepaticojejunostomy group (1 bleeding and 1 bacteremia) and 17% in the choledochoduodenostomy group (1 biloma, 1 bleeding and 1 stent migration). All immediate complications were successfully managed nonsurgically except the stent migration. No late procedure related complications were found in both groups during the follow-up time. Conclusion: Statistical analysis revealed no difference in the procedure time (p 0,24), success and complication rate (p 0,766) in this series. More studies are warranted to clarify the role of each drainage route.