Biliary Decompression Research Articles

When Is It Safe to Proceed With Pancreaticoduodenectomy Without Biliary Decompression?

An absolute bilirubin level where preoperative biliary decompression (PBD) is indicated before pancreaticoduodenectomy has been elusive. Our goal was to identify a total bilirubin level whereby biliary decompression provides clear benefit, despite associated expenses and potential complications. We reviewed a prospectively collected database of patients undergoing pancreaticoduodenectomy at the Vidant Medical Center between 2007 and 2016. Patients were arbitrarily subdivided into 3 groups based on presenting bilirubin level (≤10mg/dL, 10.1-14.9mg/dL, and ≥15mg/dL) to determine the presence of overall complications, severe complications (Clavien-Dindo classification ≥3), prolonged length of stay (>1 SD), readmissions, or mortality. Common bile duct stenting independently predicted a higher incidence of complications in patients presenting with bilirubin ≤10mg/dL (P = .03) vs. those patients going directly to surgery. No differences were observed for patients with bilirubin between 10.1mg/dL and 14.9mg/dL. Biliary decompression in patients with bilirubin ≥15mg/dL independently predicted fewer overall (73.8% vs. 100%, P = .0082) and less severe complications (14.3% vs. 44.5%, P = .03) and lower readmission rates (15.8% vs. 55.6%, P = .03) vs. those going directly to surgery. Patients not undergoing biliary decompression underwent pancreaticoduodenectomy sooner than those decompressed (4.7days vs. 17.2days, P = .01). All patients presenting with bilirubin ≥15mg/dL should undergo PBD, while those with bilirubin ≤10mg/dL should forego stent placement to avoid stent-related complications. The decision to stent between 10.1 and 14.9mg/dL should be made on a case-by-case basis keeping in mind timeliness to definitive cancer treatment.

S1382 The Great Imitator: A Case of Early Onset Pancreatic Cancer

INTRODUCTION: Pancreatic cancer (PC) is one of the deadliest malignancies, and represents the fourth leading cause of cancer death in the United States. According to the Surveillance, Epidemiology, and End Results (SEER) registry, fewer than 2 percent of patients with PC are under the age of 45. Those who are diagnosed with PC at a younger age consistently show better outcomes, including overall, progression-free and disease-free survivals. CASE DESCRIPTION/METHODS: We present a case of a 35-year-old woman with past medical history of cholelithiasis status post endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and extraction of choledocholiths followed by cholecystectomy at the age of 20 and morbid obesity status post laparoscopic gastric sleeve at the age of 30 who was referred for ERCP with extraction of choledocholiths. She underwent a magnetic resonance imaging (MRI) which revealed a 3.1 × 2.8 cm mildly heterogeneously enhancing pancreas head mass (Figure 1A) associated with marked upstream dilation of the biliary tree (Figure 1B). Endoscopic ultrasonography (EUS) revealed a 23.7 × 22.1 mm hypoechoic heterogeneous pancreas head mass with ill-defined borders. Fine needle biopsy (FNB) was performed (Figure 2A) with pathology revealing adenocarcinoma (Figure 2B). Due to external compression of pancreas mass on duodenum, major ampulla was not visualized, and ERCP was performed by rendezvous technique in conjunction with interventional radiology (Figure 3A). A transpapillary fully covered self-expanding metal stent (FC-SEMS) was successfully deployed resulting in biliary decompression (Figure 3B). As there was no imaging evidence of metastatic disease, patient was referred for resection with curative intent after neoadjuvant chemotherapy administration. DISCUSSION: PC prevalence in patients under the age of 50 remains rare. Certain risk factors for early onset are similar to those for late onset PC. These include alcohol use, tobacco use, chronic pancreatitis, diabetes mellitus, obesity and previous cholecystectomy or gastrectomy. In early onset PC, special attention should be paid to molecular genetics. The typical oncogenes, such as KRAS and c-Myc, and tumor suppressor genes, such as TP53, CDKN2a and SMAD4, still play a role, however, special attention should be paid to BRCA 1 and BRCA 2 germline mutations, as these patients show a particularly early disease onset. Surgical resection is the only curative therapeutic approach, and early detection is essential to ensure resectability.Figure 1.: (A) MRI axial image displaying pancreatic head mass; (B) MRCP coronal image displaying biliary ductal dilation upstream from pancreatic mass.Figure 2.: (A) EUS image with FNB of pancreatic head mass; (B) pathology slide displaying high magnification image of pancreatic adenocarcinoma.Figure 3.: (A) Biliary access achieved by rendezvous technique with interventional radiology; (B) Transpapillary fully covered self expanding metal stent successfully deployed.

S2379 A Unique Approach in Selective Guidewire Cannulation of a Complex Malignant Biliary Stricture

INTRODUCTION: Digital single-operator cholangioscopy (D-SOC), such as Spyglass DS, represents newer technology that can improve the diagnostic and therapeutic capabilities of ERCP. In the case below, we present how the use of Spyglass aided in the decompression of a complex malignant biliary stricture. CASE DESCRIPTION/METHODS: 52 year old male presented with epigastric pain, and obstructive jaundice. Patient has known portal vein thrombosis, and metastatic adenocarcinoma to the liver and lungs. The primary is suspected to be of upper GI or pancreatobiliary origin.CBC, PT INR, and BMP were within normal limits. T Bili is 17 mg/dL, D Bili 12.5 mg/dL, Alk Phos 1441 units/L, AST 300 units/L, ALT 251 units/L, AFP 11.5 ng/mL, CEA 249.8 ng/mL, and CA 19–9 113,888 units/mL. MRCP: Abrupt cut off of the distal common hepatic duct with intrahepatic bile duct dilatation.ERCP found 2 high grade biliary strictures. Conventional guidewire cannulation of the strictures were unsuccessful.A second ERCP was performed with the aid of Spyglass DS. Under direct visualization from Spyglass and fluoroscopy, guidewire cannulation of the high-grade common bile duct and hepatic duct strictures were achieved. A fully covered 10 Fr x 80mm metal stent was advanced over the guidewire and deployed across both strictures. Then, the waist of the stent was balloon dilated to 6 mm. Biliary drainage was confirmed upon scope retraction. Patients bilirubin downtrended and he was discharged with oncology follow up. DISCUSSION: The incidence of malignancy related biliary obstruction is increasing. The majority of these patients will benefit from biliary decompression in order to improve quality of life. Given the complications associated with percutaneous transhepatic biliary drains and stenting of biliary strictures, therapeutic ERCP is the favored approach. However, even the most experienced endoscopists fail to cannulate malignant strictures 5-10% of the time with conventional ERCP. Based on our experience, the utility of Spyglass DS might be of benefit when managing difficult malignant biliary strictures. Upon our literature review, the use of D-SOC guided cannulation of these strictures were found in only 11 patients, with 64% having cholangiocarcinoma. With the aid of D-SOC, the success rate of cannulation was 46%. Given limited literature, more research for this procedural indication should be considered as D-SOC could be a viable approach in improving the effectiveness of endoscopic management of these complex malignant strictures.

S3334 No Fluoroscopy, No Problem: Non-Fluoroscopic, Non-Sonographic Biliary Drainage

INTRODUCTION: Acute cholangitis (AC) is classically associated with fever, right upper quadrant pain, and jaundice. Severe AC is a gastrointestinal (GI) emergency that requires urgent intervention. The most common cause of AC is biliary obstruction due to gallstones. The management of severe AC involves early initiation of antibiotics, aggressive resuscitation, and endoscopic retrograde cholangiopancreatography (ERCP). We present a case of severe AC requiring an urgent ERCP that was complicated by fluoroscopy malfunction with successful stent placement. CASE DESCRIPTION/METHODS: A 27-year-old man with a past medical history of autism presented with jaundice and fever. The patient is nonverbal and developed nausea and emesis for 3 days prior to presentation. The patient developed jaundice which prompted medical evaluation. On evaluation, the patient was tachycardic and febrile and was directed to the emergency department (ED). In the ED, abdominal ultrasound showed a CBD measuring 15mm. Initial labs were notable for WBC 21.8k, AST 171, ALT 254, and direct bilirubin >10. The patient was given antibiotics and underwent urgent ERCP. Upon biliary cannulation, pus and bile was released from the papilla. Following cannulation however, the fluoroscopy equipment malfunctioned and was no longer available. Given severe AC and aspiration of pus/bile, one plastic biliary stent was placed under endoscopic guidance. The patient’s labs and vital signs rapidly improved, and he was discharged on oral antibiotics. DISCUSSION: Severe AC requires antibiotics, fluids, and timely ERCP. Although endoscopic ultrasound (EUS) is accurate in diagnosing choledocholithiasis, it is unclear whether EUS-guided biliary drainage is as effective as ERCP. One randomized trial of patients with malignant biliary obstruction showed similar success rates among those undergoing EUS-guided drainage compared to ERCP. Another randomized trial of patients with choledocholithiasis found EUS-guided ERCP without fluoroscopy to be inferior to ERCP with fluoroscopy. In our patient, ERCP with fluoroscopy was unavailable due to a technical malfunction. Although EUS was not attempted, we successfully decompressed the biliary tree with blind stent placement after confirming pus and bile on aspiration. Although ERCP with fluoroscopy is preferred, EUS-guided drainage may be a safe alternative. Biliary decompression without EUS or fluoroscopy may be a viable bedside option in patients too sick for transfer, or in situations where fluoroscopy is unavailable.

S1571 A Case of Cholangiocarcinoma Causing Severe Hyperlipidemia That Improved With Biliary Decompression

INTRODUCTION: Cholestasis causes disturbances to cholesterol homeostasis in the epithelium of the biliary tract and also to the composition and metabolism of plasma lipoproteins, which can manifest as hyperlipidemia. However extreme degree of hyperlipidemia with high levels of lipoprotein-X is unusual outside the setting of primary biliary cholangitis. We present a patient with cholangiocarcinoma (CCA) who was noted to have severe hyperlipidemia that resolved with biliary stenting. CASE DESCRIPTION/METHODS: A 70 year-old man with a past medical history of hypertension and diabetes mellitus presented with abdominal pain, jaundice, and pruritus. Computed tomography (CT) scan revealed severe intrahepatic biliary ductal dilatation with abrupt cut-off at the level of the common hepatic duct (CHD). In addition to markedly elevated liver tests with a total bilirubin of 26.2 mg/dL, his labs revealed severe hyperlipidemia with low-density lipoprotein (LDL) > 1600 mg/dL. The patient underwent endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP) and was found to have two distinct biliary strictures, one at the distal common bile duct (CBD) and another at the CHD, without any pancreatic mass. A plastic biliary stent was placed. Biliary brushings were positive for malignant cells and the patient was deemed fit for surgical resection based on imaging criteria. Endocrinology was consulted to optimize lipids and for consideration of plasmapheresis prior to surgery. A lipoprotein electrophoresis was sent to confirm the diagnosis. The patient subsequently underwent cardiac work-up, including stress testing, which was normal. He required an additional plastic stent placement 7 days after the initial ERCP and his lipid levels improved rapidly with biliary stenting over a span of 2 weeks. Later at exploratory laparotomy, his disease was found to be more extensive and unsuitable for complete resection. The patient is currently receiving chemotherapy and is in stable condition with plans to reassess for resection following treatment. DISCUSSION: Hyperlipidemia may occur in the setting of cholestasis and is often secondary to the accumulation of abnormal lipoprotein particles such as lipoprotein-X. Such particles are unlikely to be atherogenic and seldom require therapy other than treatment of the underlying cholestatic condition. In our case, a patient with cholangiocarcinoma had dramatic improvement in his cholesterol upon biliary decompression coinciding with a decrease in his cholestasis and pruritus.Figure 1.: CT showing ill-defined partially cystic CBD lesion, and stricture of the common hepatic duct.Figure 2.: Decrease in total bilirubin and LDL after stents placed on April 28 and May 5.Figure 3.: Cholangiogram showing biliary strictures (arrows).

S0924 Is Afferent Limb Length in Post-Pancreaticoduodenectomy Patients a Limiting Factor for Endoscopic Retrograde Cholangiopancreatography?

INTRODUCTION: Despite the advances in modern endoscopy, endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge in patients who are post-pancreaticoduodenectomy (PD). For post-PD reconstruction, the choledochojejunostomy and pancreaticojejunostomy are frequently placed on a single limb of the jejunum to create the afferent limb. This study evaluated the technical and clinical success rates of ERCP in post-PD patients relative to their afferent limb length (ALL). METHODS: We retrospectively evaluated patients with prior classic or pylorus-preserving PD who received ERCP from 01/13/06 to 01/16/19. Operative reports were analyzed for anatomical post-PD reconstruction details. Outcomes included: endoscopic access to the anastomosis of interest, technical success rate—the ability to treat stricture with dilation or stent placement, and clinical success rate—a documented decrease in bilirubin to normal or 50% of peak value within 2 weeks. Statistical analysis was done using Stata/SE version 16.0. RESULTS: A total of 28 patients (75% male; median age 66 years, range 22–86 years) with prior PD (20 classic PD; 8 pylorus-preserving PD) received 66 ERCPs [Table 1]. The median ALL was 42.5 cm (range 40–65 cm) in both surgical groups, 40 cm (range 40–60 cm) in those with pylorus-preserving PD, and 45.0 cm (range 40–65 cm) in those with classic PD. The most commonly used endoscope to reach the anastomosis of interest was a therapeutic upper endoscope (n = 31, 47.0%) [Table 2]. For biliary decompression, the choledochojejunostomy was reached on 16/25 initial ERCPs (64%), and on 54/63 (85.7%) total ERCPs when repeat attempts were included. All 3 ERCPs performed for pancreatic intervention were unsuccessful. The technical success rate was 81.0% (51/63 ERCPs) and the clinical success rate was 76.2% (48/63 ERCPs) [Table 3]. In the 9 patients where the enterobiliary anastomosis was not identified, 2 had pylorus-preserving PD, 7 had classic PD, and the median ALL was 40.0 cm (range 40-65). Unsuccessful ERCPs were attributed to sharp bowel angulations (n = 5), poor visibility (n = 1), and ALL (n = 2; length >65 cm). There were no perforations or bleeding. CONCLUSION: Overall, ERCP was limited by excessively long afferent limbs (lengths >65 cm), but more commonly by sharp bowel angulations that prevented endoscope advancement. Improvements are necessary for the endoscopic management of the pancreaticojejunostomy in patients who are post-PD.Table 1.: All enteric anastomosis were placed on a single limb of the jejunum to create the afferent limbTable 2Table 3

Multidisciplinary Approach to Malignant Biliary Obstruction

AbstractTreatment of malignant biliary obstruction (MBO) requires the coordination of multiple specialties, including oncologists, surgeons, gastroenterologists, and interventional radiologists. If the tumor is resectable, surgical candidates can usually proceed to surgery without preoperative biliary drainage. For patients who undergo biliary drainage, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) combined with biliary stenting are techniques with comparable technical success and mortality, each with distinct advantages and risks. Advances in endoscopic ultrasound allow drainage in patients with challenging anatomy. There are a multitude of devices used for biliary decompression. Self-expanding metal stents (SEMS), with longer patency rates, are in most instances preferred over plastic stents for MBO, especially in patients with life expectancy more than 3 to 4 months. Advantages of covered SEMS versus uncovered SEMS remain controversial as covered stents can prevent tumor ingrowth but at the expense of potential increase in stent migrations. Extra-anatomic biliary drainage using lumen-apposing metal stents is an emerging technique which shows promise when conventional ERCP fails. It is imperative to understand these techniques when tailoring a treatment strategy. The goal of this article is to discuss a multidisciplinary approach for MBO to promote comprehensive care using case examples to highlight essential principles.

Aspergillus fumigatus cholangitis in a patient with cholangiocarcinoma: case report and review of the literature

Aspergillus spp. cholangitis is an uncommon presentation of invasive aspergillosis. Only few cases are described in the literature affecting severely immunocompromised patients or patients following biliary surgery. Especially, invasive aspergillosis in non-haematological patients is associated with high mortality rates, caused by atypical presentations, which is associated with a delay in diagnosis and therapy. We report a 72-year-old man with primary diagnosis of cholangiocarcinoma and stent implantation by endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression who developed severe cholangitis with invasive aspergillosis. The patient had no history of prior hospitalisation, no immunosuppressive therapy and no preceding biliary surgery. Furthermore, in this exceptional case of extrapulmonary aspergillosis, there were no signs of pulmonary involvement. From the literature review, only three cases of Aspergillus cholangitis could be identified. Clinical manifestations of invasive aspergillosis can be variable and classical risk factors such as immunosuppression are not mandatorily present. Clinical awareness of these rare cases is of vital importance for initiation of correct therapy.

Combined Versus Separate Sessions of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography for the Diagnosis and Management of Pancreatic Ductal Adenocarcinoma with Biliary Obstruction.

A single-procedure session combining EUS and ERCP (EUS/ERCP) for tissue diagnosis and biliary decompression for pancreatic duct adenocarcinoma (PDAC) is technically feasible. While EUS/ERCP may offer expedience and convenience over an approach of separate procedures sessions, the technical success and risk for complications of a combined approach is unclear. Compare the effectiveness and safety of EUS/ERCP versus separate session approaches for PDAC. Study patients (2010-2015) were identified within our ERCP database. Patients were analyzed in three groups based on approach: Group A: Single-session EUS-FNA and ERCP (EUS/ERCP), Group B: EUS-FNA followed by separate, subsequent ERCP (EUS then ERCP), and Group C: ERCP with/without separate EUS (ERCP ± EUS). Rates of technical success, number of procedures, complications, and time to initiation of PDAC therapies were compared between groups. Two hundred patients met study criteria. EUS/ERCP approach (Group A) had a longer index procedure duration (median 66min, p = 0.023). No differences were observed between Group A versus sequential procedure approaches (Groups B and C) for complications (p = 0.109) and success of EUS-FNA (p = 0.711) and ERCP (p = 0.109). Subgroup analysis (> 2months of follow-up, not referred to hospice, n = 126) was performed. No differences were observed for stent failure (p = 0.307) or need for subsequent procedures (p = 0.220). EUS/ERCP (Group A) was associated with a shorter time to initiation of PDAC therapies (mean, 25.2 vs 42.7days, p = 0.046). EUS/ERCP approach has comparable rates of success and complications compared to separate, sequential approaches. An EUS/ERCP approach equates to shorter time interval to initiation of PDAC therapies.

Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence.

BACKGROUNDDespite advancements in operative technique and improvements in postoperative managements, postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD). There are some reports to predict POPF preoperatively or intraoperatively, but the accuracy of those is questionable. Artificial intelligence (AI) technology is being actively used in the medical field, but few studies have reported applying it to outcomes after PD.AIMTo develop a risk prediction platform for POPF using an AI model.METHODSMedical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016. A total of 38 variables were inserted into AI-driven algorithms. The algorithms tested to make the risk prediction platform were random forest (RF) and a neural network (NN) with or without recursive feature elimination (RFE). The median imputation method was used for missing values. The area under the curve (AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.RESULTSThe number of POPFs was 221 (12.5%) according to the International Study Group of Pancreatic Fistula definition 2016. After median imputation, AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN. The maximal AUC using NN with RFE was 0.74. Sixteen risk factors for POPF were identified by AI algorithm: Pancreatic duct diameter, body mass index, preoperative serum albumin, lipase level, amount of intraoperative fluid infusion, age, platelet count, extrapancreatic location of tumor, combined venous resection, co-existing pancreatitis, neoadjuvant radiotherapy, American Society of Anesthesiologists’ score, sex, soft texture of the pancreas, underlying heart disease, and preoperative endoscopic biliary decompression. We developed a web-based POPF prediction platform, and this application is freely available at http://popfrisk.smchbp.org.CONCLUSIONThis study is the first to predict POPF with multiple risk factors using AI. This platform is reliable (AUC 0.74), so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.

Features of mechanical jaundice course caused by complications of bile disease

The OBJECTIVE was improving the results of diagnostics and assessment of the severity of patients with mechanical jaundice (MJ) at various stages of its development.METHODS AND MATERIALS. The basis of clinical and laboratory research was the data of 537 patients who were admitted during the period from 2010 to 2019. Principles of separation at the stage of the course of mechanical jaundice of non-tumor Genesis.RESULTS. Analysis of clinical and laboratory studies showed characteristic signs of various complications of cholelithiasis, accompanied by mechanical jaundice. Then, on this basis, specific symptoms characteristic of each stage of mechanical jaundice of non-tumor Genesis were determined.CONCLUSION. The course of mechanical jaundice, which develops with complications of cholelithiasis, has a phase-stage character, beginning with extrahepatic cholestasis, then-joining hepatocytolysis and ending with cholangitis. Initially, cholestasis and cytolysis are functional, which is confirmed by biochemical tests, so these processes are labile and reversible. This makes it possible to effectively use biliary decompression methods and infusion therapy with detoxification during treatment. Cholangitis is characterized by destructive morphological manifestations, so it is verified by specific clinical symptoms and laboratory tests characteristic of inflammatory-septic reactions and progresses to sepsis. Differentiation of stages of mechanical jaundice allows to personify surgical and conservative treatment of such patients.

Characteristics of Pancreaticoduodenal Resection on Periampullary Tumor Cases by Jakarta Tertiary Hospital Team: Three Decade Report

Background: There were only few publications related to pancreaticoduodenal resection (PDR) /Whipple procedure in Indonesia in the past decade.Method: Retrospectively report of the characteristics and outcomes of PDR performed by Cipto Mangunkusumo Hospital surgical team from 1993 to 2017 were collected.Results: PDR were performed in 213 patients, with a mean age of 50.6 years and 54.4% patients were females. Predominant preoperative clinical findings were jaundice (68.9%) and mild hypoalbuminemia (69.9%). Biliary decompression was performed in 112 (52.6%) subjects. Average surgical waiting time was 3.5 months. While PDR were performed in 84 (39.5%) subjects, pyloric preserving pancreaticoduodenal technique was predominated in 128 (59.8) and predominated, especially during the latter years. Fifteen (9.0%) cases were benign. Thirty-one (14.6%) subjects underwent relaparotomy, 16 (51.6%) of whom died post-operatively. Overall operative mortality decreased from 16.9% to 5.5% in 2016, while resection rate generally increased over time, ranging from 2 - 21/year. Less than 10% of subjects survived for 5 years, while 20% survived for 24 months. Overall morbidity was 65.1% in 177 survivors, with surgical site infection in 52.5%, pancreatic fistula in 24.2%, and post-pancreatectomy haemorrhage (PPH) as a fatal postoperative complication in 19 (8.9%) cases. Patients who died within 30 days postoperatively had significantly more relaparotomies and PPH (p 0.001).Conclusion: Prolonged jaundice and mild hypoalbuminemia are dominant characteristics in our Indonesian PDR subjects. Cipto Mangunkusumo Hospital is a high-volume PDR centre and world class hospital. Mortality rates decreased with the increasing resection rates. Relaparotomy and PPH are predictors of poor outcome.

Endoscopic ultrasound-guided hepaticogastrostomy using a partially covered metal stent in patients with malignant biliary obstruction after failed Endoscopic retrograde cholangiopancreatography.

Background and AimThe advent of endoscopic ultrasound‐guided biliary drainage (EUS‐BD) has provided an inimitable alternative for gaining biliary access in patients who fail conventional endoscopic drainage. The antimigratory features of the partially covered metal stent (PCMS), namely, the flange head and uncovered portion of the stent, makes it a valuable option in patients undergoing EUS‐guided hepaticogastrostomy (EUS‐HGS). The aim of the study is to evaluate the clinical outcome of EUS‐BD via the hepaticogastrostomy approach using PCMS in patients with malignant biliary obstruction after failed ERCP.MethodsThis is a single‐center retrospective observational study of patients with malignant biliary obstruction undergoing EUS‐HGS after failed ERCP between January 2018 and May 2019. The end‐point of the study was to assess the technical and clinical success rate, as well as the stent‐ and procedure‐related complications.ResultsThere were 20 subjects in this study. The average age was 71.8 ± 7.6 years. Most patients were male, 16 (80%). Inaccessible papillae was the most common indication for this procedure, 16 (80%). Technical success was achieved in all patients. The average procedural time was 39.9 ± 1.3 min. Mean preprocedural bilirubin levels were 348.6 ± 28.8 and subsequently decreased to 108.94 ± 37.1 μmol/L at 2 weeks postprocedure. The clinical success rate was 95% (19/20), with one patient requiring percutaneous transhepatic biliary drainage (PTBD). There were no stent‐ or procedure‐related complications reported in this study.ConclusionEUS‐HGS with PCMS is a feasible, effective, and safe alternative for biliary decompression in patients with failed endoscopic retrograde cholangiopancreatography (ERCP).

Malignant obstructive jaundice: justification of the method of biliary decompression

Aim. To show the optimal algorithm of diagnostic and treatment of malignant obstructive jaundice, which allows to increase the effectiveness of primary surgery, reducing the number of complications and mortality in the operated patients.Materials and methods. The results of examination and surgical treatment of 325 patients with malignant obstructive jaundice who underwent minimally invasive decompression of the biliary tract were studied. Based on the results of treatment, an algorithm for examining and treating patients with malignant obstructive jaundice has been formed and tested.Results. Using such criterial like severity of obstructive jaundice by E.I. Galperin, anatomical level of biliary tract occlusion and staging oncology process by TNM classification could help to choose the rational method for its surgical treatment and determine the risk of complications and mortality. At the level of biliary occlusion I and II, endoscopic stenting is a fairly successful inter-vention with a minimum of complications. For a level III block, the operation of choice is percutaneous transhepatic drainage. Cholecystostomy is advisable in case of level I block below the cystic duct in flow level and class “C” obstructive jaundice or for technical impossibility to apply a different method.Realization of the developed algorithm allowed resolving obstructive jaundice in a palliative option in 71.4% of patients and preparing 28.6% for surgical treatment.Conclusion. Implementation of an improved algorithm for the diagnosis of malignant obstructive jaundice makes it possible to justify the choice of a rational option for its surgical treatment, increase the effectiveness of interventions and reduce postoperative mortality.

Drug Eluting Versus Covered Metal Stents in Malignant Biliary Strictures-Is There a Clinical Benefit?: A Systematic Review and Meta-Analysis.

Patients with malignant biliary obstruction (MBO) often require transpapillary stenting for symptomatic relief and biliary decompression. Plastic stents and uncovered metal stents are now replaced by covered self-expanding metal stents (SEMS). However, stent occlusion from tumor overgrowth and chronic inflammation continues to be an issue. Drug-eluting stents (DES), through an antitumor paclitaxel membrane, have been used to combat this problem. The aim of this study was to conduct a meta-analysis comparing DES to SEMS in MBO. Multiple databases were searched to identify studies that compared the clinical outcomes of SEMS and DES in patients with MBO. Random-effects model was used to calculate the pooled odds ratio and the pooled individual outcomes. Our primary goals were to assess the stent patency and overall survival in days. Secondary outcomes assessed the individual reported adverse events and/or complications. Five studies including 348 patients (175 males and 173 females) were included. The pooled odds ratio of stent patency was 1.03 (95% confidence interval: 0.68-1.54, P=0.9) and overall survival was 1.16 (95% confidence interval: 0.63-2.11, P=0.6). The pooled rate of stent patency was 168.3 (95% 140.7-196.4) days for DES and 149.4 (117.6-181.2) days for SEMS. The pooled rate of overall survival was 267.2 (206.2-328.2) days for DES and 218.2 (148.5-287.8) days for SEMS. On the basis of this meta-analysis, DES and SEMS seem to demonstrate comparable clinical outcomes in patients with malignant biliary strictures. Reported adverse events and/or complications were comparable as well.

Folfirinox chemotherapy prolongs stent patency in patients with malignant biliary obstruction due to unresectable pancreatic cancer

Background: Stent insertion for biliary decompression to relieve jaundice and subsequent biliary infection is necessary for patients with biliary obstruction caused by pancreatic cancer, and it is important to keep the stent patent as long as possible. However, few studies have compared stent patency in terms of chemotherapy in patients with pancreatic cancer. This study aimed to evaluate the differences in stent patency in terms of recently evolving chemotherapy.Methods: Between January 2015 and May 2017, 161 patients with pancreatic cancer who had undergone biliary stent insertion with a metal stent were retrospectively analyzed. The relationship between chemotherapy and stent patency was assessed. Additionally, overall survival according to the treatment, risk factors for stent patency, and long-term adverse events were evaluated.Results: Median stent patency was 42 days for patients with the best supportive care and 217 days for patients with chemotherapy (conventional gemcitabine-based chemotherapy and folfirinox) (P < 0.001). Furthermore, the folfirinox group showed the longest median stent patency and overall survival, with 283 days and 466 days, respectively (P < 0.001) despite higher adverse events rate. Patients who underwent folfirinox chemotherapy after stent insertion had better stent patency in multivariate analysis (HR = 0.26; 95% CI: 0.12–0.60; P = 0.001).Conclusions: Compared with patients who received best supportive care only, patients who underwent chemotherapy after stent insertion had better stent patency. More prolonged stent patency can be expected for patients with folfirinox than conventional gemcitabine-based chemotherapy.

Su1556 FEASIBILITY AND SAFETY STUDY OF A TEMPORARY BILIARY STENT FOR PROPHYLAXIS OF POST-ERCP CHOLANGITIS AFTER STONE REMOVAL

Endoscopic treatment of common bile duct stone is usually performed through the major papilla. Despite sphincteroplasty through EST or endoscopic papillary large balloon dilatation (EPLBD), edema of papilla is common after treatment, that may induce cholangitis with cholestasis (post-ERCP cholangitis: PEC). Although few cases of post-ERCP cholangitis progress to severe cholangitis, it can cause prolongation of hospital stay. To avoid this complication, biliary decompression is sometimes necessary in addition to stone removal. In such a case, ENBD or biliary stent are employed, that causes discomfort to the patient, or that requires another endoscopic session to remove the inserted stent. This retrospective study evaluates prophylactic effect of a temporary biliary stent to prevent PEC which dislodges after commencement of oral intake. Between April 2011 and May 2017, endoscopic treatment of common bile duct stones was performed on 2055 naive cases in our hospital. Among them, temporary biliary stents were employed in 190 patients in the first session. To select the patients to compare the feasibility and safety of a temporary stent between stent group and non-stent group in a reduced bias condition, propensity score matching was introduced. As a temporary biliary stent, we used 5Fr.-5cm Geenen type stent (COOK), which has a flap on only one side. After complete stone removal which was checked by balloon occlusion cholangiogram, the deployment of a temporary was decided within operator’s discretion. The PEC was defined as oral intake delay which was decided by fever and abdominal pain with abnormal liver function test. The severity of PEC was classified according to Cotton’s criteria. The dislodgement of deployed stent was confirmed by an abdominal X-ray after oral intake. Other adverse events including post-ERCP pancreatitis were also evaluated. A total of 72 pairs of patients were selected by propensity score matching. The incident rate of PEC in stent group was significantly lower than non-stent group (1.4% vs 11.1%, p=0.033). In all cases, severity of PEC was mild or moderate. The length of hospital stay in stent group were significantly shorter than in non-stent group (6.5 days vs 8.3 days, p=0.038). The rate of PEP was 7% in stent group and 5% in non-stent group (NS; p=0.83). In 3 cases (4%) of stent group, stent retention in CBD was observed, which was successfully removed endoscopically. No other severe adverse event such as perforation of retained stent was observed. Temporary biliary stents are suggested to have preventive effects of post-ERCP cholangitis and shorten hospitalization.

Su1574 DRUG-ELUTING METAL STENTS IN MALIGNANT BILIARY STRICTURES AND HOW THEY COMPARE TO COVERED SELF-EXPANDING METAL STENTS: A META-ANALYSIS

Patients with malignant biliary obstruction (MBO) often require transpapillary stenting for symptomatic relief and biliary decompression. The evolution of stent selection in treating MBO has quickly evolved over time. Plastic stents and uncovered metal stents are now replaced by covered self-expanding metal stents (SEMS). However, despite these advances stent occlusion from tumor overgrowth and chronic inflammation continues to be an issue. Drug-eluting stents (DES), through an antitumor paclitaxel membrane, have been used to combat this problem. It is yet to be determined if these novel DES can indeed surpass SEMS. The aim of this study was to conduct a meta-analysis comparing DES to SEMS in MBO. Multiple databases were searched to identify studies that compared the clinical outcomes of SEMS and DES in patients with MBO. Random-effects model was used to calculate the pooled odds ratio (OR) and the pooled individual outcomes. Heterogeneity was assessed using I2 statistics. Our primary goals were to assess stent patency and overall survival in days. Secondary outcomes assessed the individual reported adverse events and/or complications. Five studies including 348 patients (175 Males, 173 Females) were included in the final analysis. All studies were conducted in South Korea. Average age ranged from 58.9 to 79.1 years. The mean follow up period ranged from 143 days to 329 days. 43% (n=151) and 57% (n=197) of patients underwent placement of SEMS and DES, respectively. The pooled OR of stent patency was 1.03 (95% CI 0.68-1.54, I2=0, p=0.9) and overall survival was 1.16 (95% CI 0.63-2.11, I2=65, p=0.6). The pooled rate of stent patency was 168.3 (95% 140.7-196.4, I2=76) days for DES and 149.4 (117.6-181.2, I2=0) days for SEMS. The pooled rate of overall survival was 267.2 (206.2-328.2, I2=88) days for DES and 218.2 (148.5-287.8, I2=66) days for SEMS. Pooled results of individual adverse events and/or complications are summarized in table 1. Based on this meta-analysis, DES and SEMS seem to demonstrate comparable clinical outcomes in patients with malignant biliary strictures. Reported adverse events and/or complications were comparable as well. Given our results, a cost-effectiveness analysis of using DES is warranted in this patient population.

Biliary Drainage Before and After Liver Resection for Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR <50%. Biliary drainage for resectable PHC requires a patient-specific approach with careful determination of the FLR and balancing of potential morbidity with the benefits of drainage.

Su1289 COMPARISON OF EUS-GUIDED RENDEZVOUS AND PERCUTANEOUS BILIARY DRAINAGE IN PATIENTS FAILED STANDARD ERCP

Endoscopic retrograde cholangiography (ERCP) is the procedure of choice for biliary decompression in patients with obstructive jaundice. In cases of failed procedure, percutaneous biliary drainage (PBD) is currently the mainstream of alternative care. On the other hand, EUS-guided rendezvous (EUS-RV) drainage is gaining popularity of reported high technical success. Current literature mostly focuses on EUS-guided transluminal drainage, while only few studied on the role of EUS-RV. We aimed to compare the success rate, efficacy and safety of EUS-RV drainage over standard care as the rescue therapy. This is a retrospective cohort study reviewing cases underwent ERCP for both malignant and benign biliary obstruction at Prince of Wales Hospital in Hong Kong, an university-affiliated tertiary referral center. From January 2013 to October 2019, a total of 6294 ERCPs were performed with 179 (2.84%) failed. 32 cases underwent EUS-RV drainage while 23 cases were referred to intervention radiologists for either urgent percutaneous cholecystostomy (PTC) or percutaneous transhepatic biliary drainage (PTBD). Comparisons were made between the two groups regarding technical success, clinical achievement of biliary drainage, duration of hospital stay and adverse outcomes after procedure. Majority (71.8%) of EUS-RV cases suffered from biliary stone diseases. About half (53.1%) failed ERCP despite prior attempt of precut sphincterotomy. Over 70% of patients managed to access biliary tree with one single puncture only. In total, four cases failed EUS-RV drainage, while two succeeded after switching puncture site from transduodenal to transgastric. Patients in the EUS-RV drainage group were significantly older than the PBD arm (81 years-old vs 71 years-old, p = 0.012). In terms of technical success of biliary drainage, EUS-RV drainage was comparable to PBD (87.5% vs 87%, p=0.952) with similar degree of bilirubin drop by greater than 50% in 1 week (51.9% vs 44.4%, p=0.63). Fewer patients required repeated biliary intervention within 2 weeks after EUS-RV drainage than PBD (1/32 vs 5/23, p = 0.006). The mean length of hospital stay after procedure was 8 days shorter in the EUS-RV than the PBD group (9.6 days vs 17.7 days, p=0.076). Although overall complication rate of EUS-RV (21.9%) was slightly higher than that of PBD (13.7%), most were due to post-ERCP pancreatitis and the difference was not clinically significant (p=0.40). Only one procedure-related death due to bleeding was reported in the PBD group, while none from the EUS-RV group. EUS-RV drainage is a feasible alternative to PBD in patients with biliary obstruction after failing ERCP with precut. It showed a promising success rate up to 87.5% when expertise available, lower rate of re-intervention and shorter post-procedural hospital stay.View Large Image Figure ViewerDownload Hi-res image Download (PPT)