Tu1622 Primary Anterograde EUS-Guided Biliary Interventions for Failed ERCP

Abstract

Tu1622 Primary Anterograde EUS-Guided Biliary Interventions for Failed ERCP Frank Weilert* Department of Gastroenterology, Waikato Hospital, Hamilton, New Zealand Background: EUS-guided biliary drainage (EUS-BD) is technically challenging but an alternative method of therapeutic intervention when ERCP fails. Objective: Assess the feasibility, safety and risks of EUS-BD with intra-hepatic biliary access and anterograde interventions to increase flexibility of interventions, limit adverse events and improve procedural time. Design: Prospective observational cohort study Patients: 25 consecutive patients underwent EUS-BD drainage for failed ERCP. Main Outcome measures: Technical and clinical success rates with adverse event rate. Results: Patient recruitment from June 2011-Sep 2014; 25 patients with a mean age of 68.6 years, predominantly male (68%) with pancreatic cancer (48%), cholangiocarcinoma (20%), other malignant biliary obstruction (8%) and benign biliary obstruction (21.7%). Prior interventions included failed ERCP in 22/25 (88%) while 3/ 25 (12%) had primary EUS-BD. Anterograde cholangiogram was achieved in all patients. Technical success was achieved in 24/25 (96%) with clinical success was achieved in 23/25 (92%). Placement of access wire was across the ampulla in 13/24 (54.2%) and into CBD or contra-lateral IHD in 11/24 (44.8%). Tract dilatation was accomplished in 20/24 (83.3%) but required completion using intra-hepatic needle knife in 4/25 (16.7%). Anterograde interventions (table 1) were performed in 18/24 (75%) but crossover to rendezvous in 5/24 (20.8%) or choledochoduodenostomy 1/ 24 (4.2%). Three patients 3/25 (12%) also had endoscopic duodenal SEMS placement to relieve duodenal obstruction. Three patients (12%) had adverse event including post-procedural bile leak (1), pain (1) and subcapsular hematoma (1), respectively. Conclusion: Primary anterograde EUS-guided biliary drainage using the intra-hepatic access route has high technical and clinical success with low adverse rate. We would promote a simplified standardized algorithm (fig 1), which gives flexibility of direct anterograde interventions.