Percutaneous Biliary Drainage Research Articles

S1516 Malignant Biliary Obstruction Diagnosed by Percutaneous Transhepatic Cholangioscopy With Spyglass Direct Visualization System

INTRODUCTION: Malignant biliary obstruction associated with gastric cancer is uncommon. We report a patient with obstructive jaundice due to a new biliary stricture after gastrectomy and loop gastrojejunostomy. Conventionally, enteroscopy-assisted ERCP will be needed to biopsy the stricture which can be difficult and not widely available. Here we describe an easier approach using Percutaneous Transhepatic Cholangioscopy (PTCS) with SpyglassTM Direct visualization system (SDVS). CASE DESCRIPTION/METHODS: 51-year-old male with history of gastric adenocarcinoma status post distal gastrectomy with loop gastrojejunostomy presented 3 years later with painless jaundice. Initial imaging studies including US and CT scan showed severe biliary obstruction with pronounced intrahepatic and extrahepatic ductal dilatation. MRCP revealed a proximal common bile duct stricture with resultant severe intrahepatic ductal dilation spanning approximately 1.5 cm, highly suspicious for malignancy (Image1). ERCP was not attempted due to the altered anatomy and a percutaneous internal biliary drain was placed by Interventional radiology (IR). The drain was placed through the left biliary system into the common duct and into the duodenum. Cholangiogram showed two strictures in the proximal and mid bile duct. In order to obtain the diagnosis, the decision was made to proceed with a combined endoscopic and IR guided approach. A digital cholangioscope was passed through a 12Fr sheath catheter that was placed by IR. The stricture was endoscopically visualized and appeared erythematous, friable with whitish mucosa (Image 2). Multiple biopsies were obtained using a mini biopsy forceps. Pathology revealed poorly differentiated adenocarcinoma with associated fibrosis, inflammation and necrosis. DISCUSSION: Cholangioscopy through a percutaneous transhepatic route is an attractive alternative option when traditional ERCP is technically challenging or not feasible. SDVS provides direct visualization of the biliary system increasing the diagnostic yield, as in our case where it helped to diagnose a malignant biliary stricture in a patient who was in remission from primary gastric carcinoma. PTCS with SDVS also provides therapeutic potential for choledocholithiasis, biliary strictures and local tumor ablative therapy. Though it is an invasive procedure requiring collaboration between a gastroenterologist and an interventional radiologist, as demonstrated, it is a safe and technically easy procedure with unique diagnostic and therapeutic potentials.Figure 1.: blue arrow: Proximal common bile duct stricture causing severe intrahepatic ductal dilation.Figure 2.: Biliary stricture seen using direct visualization system.

S1390 Caroli Disease With Choledochoduodenal Fistula and SUMP Syndrome

INTRODUCTION: Choledochoduodenostomy (CDDS) is a common procedure performed in patients with recurrent, impacted bile duct stones. We present a unique case of a patient with Caroli disease and repeat choledocholithiasis with CDDS presenting with a distal choledochoduodenal fistula (DCDF) and SUMP syndrome. CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of Caroli disease, multiple abdominal surgeries including CDDS, cholecystectomy secondary to recurrent choledocholithiasis presented to the clinic with abdominal pain. Further evaluation with an MRCP revealed filling defects in the distal common bile duct suggestive of choledocholithiasis. She underwent ERCP which revealed DCDF. Multiple small stones were extracted with purulent drainage with failed cannulation of the primary system. She developed severe right upper quadrant pain and nausea shortly after ERCP and presented to the emergency department. Her vitals and labs were unremarkable. Intravenous (IV) antibiotics were started due to concerns of cholangitis. Interventional radiology (IR) placed a percutaneous biliary drainage catheter. A repeat ERCP revealed old choledocho-duodenostomy and internal and external biliary drain within the bile duct, and without cannulation of the intrahepatic duct. Fluid cultures grew Enterococcus faecium and antibiotics were added and discharged home. A biliary catheter was removed two weeks later after gadolinium spillage of contrast into the bowel was seen, showing patency. DISCUSSION: Caroli disease is a congenital disorder presenting with large intrahepatic ductal dilation with an increased risk of hepatic fibrosis. There is bile stagnation leading to recurrent cholelithiasis. CDDS is a procedure performed in recurrent choledocholithiasis leading to gallstone pancreatitis and acute cholangitis despite cholecystectomy. CDDS creates a connection between the proximal common bile duct (CBD) and the 1st portion of the duodenum. The bile no longer drains via the distal CBD, creating a reservoir called a “sump”. Lithogenic bile, debris, or calculi accumulate causes recurrent cholangitis or choledocholithiasis. DCDF occurs at the entrance of the distal CBD into the 2nd part of the duodenum and caused by impacted stones in 90% of the cases. DCDF is a rare complication from CDDS leading to SUMP syndrome. The impacted stone erodes the CBD wall leading fistulation into the duodenum. The diagnosis of DCDF is made with ERCP. Treatment requires fistulotomy, sphincterotomy, stone removal, and biliary drainage.Figure 1.: MR reconstruction of the biliary tree (A) showing a dilated proximal common bile duct (CBD) measuring 11 mm and dilated main pancreatic duct (PD) measuring 4.5 mm. MRCP (B) showing ill-defined intraluminal filling defects are seen in the distal portion of the common duct suggestive of choledocholithiasis.Figure 2.: IR guided percutaneous biliary drainage catheter placement. A: Cholangiogram with gadolinium-based contrast showed mild central biliary dilatation with abnormal anatomy and possible two outflow tracts the bowel (SB). B: An 8.5 Fr. Internal and external catheter (C) was placed.Figure 3.: IR guided percutaneous biliary drainage catheter removal. Prior to the removal of the catheter, a small amount of gadolinium was injected through the existing tube to demonstrate patency. Free spillage of contrast into the bowel (SB) is noted.

Endoscopic biliary stenting as the risk factor for cholangitis after endoscopic ultrasound in patients with biliary strictures.

Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) are established as efficient and safe diagnostic modalities. However, the risk of cholangitis after EUS/EUS-FNA (post-EUS cholangitis) in patients who have biliary strictures has not been fully examined. We retrospectively reviewed 136 consecutive inpatients with biliary strictures who received EUS/EUS-FNA at our hospital from April 2012 to September 2017 and evaluated complications that occurred by the next day after EUS/EUS-FNA. Patients with percutaneous biliary drainage, those in whom it was difficult to reach the duodenum, and those receiving concurrent endoscopic retrograde cholangiopancreatography were excluded. We included 121 patients (147 cases); 90 patients were malignant. Endoscopic biliary stenting (EBS) with plastic stents had already been performed in 86 cases. Post-EUS cholangitis was observed in 4.1% (6/147). No other EUS-related complications were observed. The incidence of cholangitis with EBS was significantly higher than that in the cases without EBS (7.0% [6/86] vs 0% [0/61], P=0.042). Biliary enzyme elevation was also identified as a risk factor of cholangitis. Endoscopic biliary stenting was identified as a risk factor associated with post-EUS cholangitis in patients with biliary strictures. Endoscopists should pay attention to post-EUS cholangitis, especially in cases with EBS and biliary enzyme elevation.

Interventional radiology in the prevention of bile duct anastomotic stricture during reconstructive surgery for the iatrogenic bile duct injury (one center experience)

Aim . To study the possibility of using radiological interventions in the staged treatment of intraoperative bile ducts injury and the prevention of biliodigestive anastomotic stricture. Materials and methods . A retrospective analysis of the treatment of 20 patients with “large” (classes B—E) iatrogenic damage to the extrahepatic biliary tract was performed. In all cases, percutaneous transhepatic cholangiostomy was performed before reconstructive Roux-en-Y hepatico- or bighepaticojejunostomy. Biliary drains installed before surgery were retained to control the anastomosis in the early postoperative period, as well as for 6 months for possible correction of the forming narrowing. Preoperatively established biliary drains were retained to control the anastomosis in the early postoperative period, as well as for 6 months for possible correction of the anastomotic stricture. Results . In 2 cases with a B-class injury, it was possible to restore the patency of the common hepatic duct by balloon dilatation without subsequent reconstructive surgery. Roux-en-Y hepatic or (bihepatico)-jejunostomy was performed in 18 patients. In 10 cases antegrade interventional radiological reconstruction of the common bile duct was performed on the external-internal drainage, including 4 cases with partial excision of the common bile duct (class E). Temporary (6 months) antegrade stenting of the partially excised right lobe duct and the confluence zone was performed in 2 cases with trauma classes D and E. There were no lethal outcomes or complications of interventional radiological surgery. Narrowing of the anastomosis was avoided in all patients. The follow-up period varied from 6 months to 13 years. Conclusion . Regardless of the period of detection of biliary tract injury in the postoperative period, tactics of stage treatment, involving the drainage of the biliary tree, with subsequent endoscopic or radiologic intervention, are advisable. Percutaneous biliary drainage in case of “large” iatrogenic injuries of the bile ducts in the postoperative period makes it possible to control biliodigestive anastomosis, timely detect and adequately correct its stricture.

Pancreaticoduodenectomy following endoscopic ultrasound-guided choledochoduodenostomy with electrocautery-enhanced lumen-apposing stents an ACHBT – SFED study

BackgroundAfter ERCP failure or if ERCP is declined for preoperative biliary drainage before pancreaticoduodenectomy, endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with electrocautery-enhanced lumen-apposing stents (ECE-LAMS) might be needed. The aim of the present study was to assess the technical feasibility and short-term outcomes of pancreaticoduodenectomy (PD) following endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with electrocautery-enhanced lumen-apposing stents (ECE-LAMS). MethodsA retrospective study of all EUS-CDS procedures with ECE-LAMS followed by PD performed in France since the availability of the device in 2016. Results21 patients underwent PD in 9 departments of surgery following EUS-CDS with ECE-LAMS. The median bilirubin level at endoscopic procedure was 292 μmol/L. A 6 mm diameter stent was used in 20 cases. No complications occurred during the procedure. During the waiting time, 1 patient had an acute pancreatitis post ERCP and 3 patients developed cholangitis, treated by either an additional percutaneous biliary drainage, or an endoscopic procedure to extract a bezoar occluding the stent, or antibiotics, respectively. PD with a curative intent was performed in all cases. Overall, postoperative mortality was nil and postoperative morbidity occurred in 17 patients (81%), including 3 with severe complications (14%). No patient developed postoperative biliary fistula. In the 21 patients followed at least 6 months, no biliary complications occurred, and no tumor recurrence developed on the hepaticojejunostomy/hepatic pedicle. ConclusionPancreaticoduodenectomy following EUS-CDS with ECE-LAMS is technically feasible with acceptable short-term postoperative outcome, including healing of biliary anastomosis.

Clinical impact of irreversible electroporation ablation for unresectable hilar cholangiocarcinoma

Irreversible electroporation (IRE) is a non-thermal ablation modality that has been shown to be safe and effective in its application to tumors that are close to risky areas. This study aims to assess the safety and efficacy of IRE for unresectable hilar cholangiocarcinoma. Nine patients from two medical centers in Asia received IRE treatment between June 2015 and July 2017. Before IRE treatment, percutaneous biliary decompressions had been performed on eight patients, and internal stenting had been performed on one patient. All patients tolerated the procedure well without high-grade complications. The ablated tumors had constant size without contrast enhancement for more than three months in eight patients and the level of CA19-9 decreased significantly in all patients. The percutaneous biliary drainage tube was removed from two patients with recanalization of the bile duct. The internal stent in one patient was removed without further stenting. The median overall survival period was 26 months, and the progression-free survival was 18 months. Bile ducts remained narrow in the majority (2/3) of the treated patients. Nevertheless, IRE ablation of unresectable hilar cholangiocarcinoma involving vital structures is a safe and feasible primary treatment for local tumor control and is effective in prolonging survival.

Hemobilia as a Complication of Transhepatic Percutaneous Biliary Drainage: a Rare Indication for Laparoscopic Common Bile Duct Exploration

BackgroundHemobilia is the presence of blood in the biliary tree and is a frequent complication after percutaneous transhepatic biliary drainage (PTBD).1 Most of these episodes are self-limited; nevertheless, in less than 5% of cases, hemobilia is clinically significant, requiring an intervention (hepatic artery embolization, stenting, or percutaneous thrombin injection).2,3 Adequate treatment requires control of hemorrhage and restoration of bile flow. Surgery is the last resort and is indicated when the other modalities fail. MethodsA 65-year-old man with multiple comorbidities was admitted with cholangitis. The patient underwent PTBD (Figure 1) but had persistent cholestasis. Thus, he underwent endoscopic cholangiopancreatography (ERCP), in which a plastic stent was misplaced within the common bile duct (CBD) and could not be removed (Figure 2). Afterwards, as the patient had persistently high bilirubin levels and the previously placed stent was malpositioned, the decision was made to proceed with laparoscopic cholecystectomy and CBD exploration. ResultsThe operation was performed with choledocoscope guidance, and the CBD was closed over a T-tube. The operative time was 280 min. Postoperative course was uneventful; the T-tube was clamped 1 week after discharge. Four weeks postoperatively, the T-tube cholangiogram showed a patent extrahepatic biliary tree with no filling defects (Figure 3). The T-tube was then removed. ConclusionsBiliary obstruction secondary to hemobilia is a rare occurrence after PTBD. Surgical CBD exploration is required when conservative management and endoscopic treatment fail and can be done successfully through a minimally invasive approach.

ERCP vs. Percutaneous Biliary Drainage in Unresectable Pancreatic Cancer

Many patients with pancreatic cancer develop jaundice at some point in their clinical course. The two most common approaches to treating biliary

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)

Risk Factors for Complications Requiring Interventional Radiological Treatment After Hepatectomy

PurposeTo identify perioperative factors that are significantly associated with complications requiring interventional radiology (IR) treatment after hepatectomy. MethodsWe retrospectively reviewed data from 11,243 patients in the USA who underwent hepatectomy from 2014 to 2016 using the National Surgical Quality Improvement Program database. Data on the following IR procedures were extracted: abscess drain placement, endovascular treatment for bleeding, and postoperative percutaneous biliary drain (PBD) placement up to 30 days postoperatively. Patients’ clinical and intraoperative factors were examined. Population, univariate, and multivariable analyses were performed. P < 0.05 was considered significant. ResultsA total of 704 patients (6%) required IR treatment postoperatively, and 10,539 patients (94%) did not. On multivariable analysis, biliary reconstruction was a significant predictor of postoperative abscess drain placement (hazard ratio (HR), 3.5; 95% confidence interval (CI) 1.8, 6.5; P < .001), endovascular treatment for bleeding (HR, 3.3; 95% CI 1.4, 7.8 P = .006), and postoperative PBD placement (HR, 2.9; 95% CI 1.9, 4.2; P < .001). Compared with hepatectomy without biliary reconstruction, hepatectomy with biliary reconstruction was associated with significantly higher rates of complications treated with IR procedures (26% vs. 4.9%) and death within 30 days (6.0% vs. 1.2%) (both, P < .001). ConclusionBiliary reconstruction is a strong predictor of the need for postoperative IR treatment after hepatectomy. One in four patients who underwent biliary reconstruction required IR treatment of a complication during the first 30 days after hepatectomy.

Double Stenting for Malignant Biliary and Duodenal Obstruction: A Systematic Review and Meta-Analysis

INTRODUCTION:Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited.METHODS:A systematic literature search was performed to assess the feasibility and optimal method of double stenting for malignant duodenobiliary obstruction compared with surgical double bypass in terms of technical and clinical success, adverse events, reinterventions, and survival. Event rates with 95% confidence intervals were calculated.RESULTS:Seventy-two retrospective and 8 prospective studies published until July 2018 were included. Technical and clinical success rates of double stenting were 97% (95%–99%) and 92% (89%–95%), respectively. Clinical success of endoscopic biliary stenting was higher than that of surgery (97% [94%–99%] vs 86% [78%–92%]). Double stenting was associated with less adverse events (13% [8%–19%] vs 28% [19%–38%]) but more frequent need for reintervention (21% [16%–27%] vs 10% [4%–19%]) than double bypass. No significant difference was found between technical and clinical success and reintervention rate of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic drainage, and endoscopic ultrasound-guided biliary drainage. ERCP was associated with the least adverse events (3% [1%–6%]), followed by percutaneous transhepatic drainage (10% [0%–37%]) and endoscopic ultrasound-guided biliary drainage (23% [15%–33%]).DISCUSSION:Substantially high technical and clinical success can be achieved with double stenting. Based on the adverse event profile, ERCP can be recommended as the first choice for biliary stenting as part of double stenting, if feasible. Prospective comparative studies with well-defined outcomes and cohorts are needed.

Hepatic biloma after minimally invasive interventional therapies: treatment and outcomes

Objective To study the treatment and outcomes of hepatic biloma after minimally invasive interventional therapies. Methods From January 2013 to December 2018, patients who underwent transcatheter arterial chemoembolization, percutaneous microwave ablation, and percutaneous biliary drainage (PTBD) at the Affiliated Hospital to Jiangnan University (Wuxi No.3 Hospital) and developed postoperative biloma that required treatment were included into this study. Results Of 43 bilomas, 14 were treated with percutaneous drainage. There were 9 males and 5 females, with an average age of 61(29-85) years. These bilomas could be classified into the following 3 types: extrahepatic bilomas (2 patients), simple bilomas (10 patients) and infected bilomas (2 patients). The treatments included PTBD, drainage of percutaneous biloma or a combination of both. Conclusion Biloma is a known complication after minimally invasive interventional therapies. These bilomas could be classified to guide treatment and to improve prognosis. Key words: Liver; Bilomas; Interventional treatment; Drainage

Management of adverse events of EUS-directed transgastric ERCPprocedure.

Background and AimsAccessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period.MethodsThis was a retrospective review of 4 patients with RYGB anatomy who underwent EDGE for the management of pancreaticobiliary disease and experienced LAMS-related adverse events. Techniques for managing and avoiding these events are discussed.ResultsFour patients underwent EDGE with both technical and clinical success. Slight LAMS migration with partial mucosal overgrowth was encountered in 1 case and was managed by LAMS removal. A large, bleeding, distal marginal ulcer after the EDGE procedure was encountered in the second case and was managed with proton pump inhibitor and removal of the LAMS, with fistula treatment with argon plasma coagulation used to enhance closure. The third case was complicated by moderate intraprocedural bleeding after LAMS dilation, which was managed by applying balloon tamponade and placing a through-the-scope esophageal stent across the LAMS. Last, preferential food passage to the excluded stomach was noted in the fourth case and resulted in symptomatic distention. The symptomatic distention was managed by another de novo jejunogastrostomy using a LAMS for drainage.ConclusionsDespite its feasibility and acceptable safety profile, the use of LAMSs during EDGE could be associated with several procedure-specific adverse events, which can be avoided or managed endoscopically with no further consequence.

Endoscopic Versus Percutaneous Preoperative Biliary Drainage in Patients With Klatskin Tumor Undergoing Curative Surgery: A Systematic Review and Meta-Analysis of Short-Term and Long-Term Outcomes.

Aims. To compare short-term and long-term outcomes of preoperative endoscopic biliary drainage (EBD) and percutaneous biliary drainage (PBD) in patients with Klatskin tumor undergoing curative surgery. Methods. We conducted a search of electronic information sources to identify all studies comparing EBD and PBD in patients with Klatskin tumor undergoing curative surgery. We used the Newcastle-Ottawa Scale to assess the risk of bias observational studies. Random-effects or fixed-effects modeling was applied as appropriate to calculate pooled outcome data. Results. We identified 9 observational studies, enrolling a total of 1436 patients. The patients in the PBD group had more advanced disease than those in EBD group in terms of Bismuth-Corlette classification and tumor classification. EBD was associated with higher risks of postprocedural complications (odds ratio [OR] =2.24, P = .001), conversion to another drainage method (OR =11.16, P < .00001), cholangitis (OR = 4.58, P < .0001), and pancreatitis (OR = 8.90, P = .009) than PBD; there was no difference between the 2 methods in terms of technical success (OR = 0.79, P = .50) and tube dislocation (OR = 0.81, P = .54). Regarding the postoperative outcomes, there was no difference in terms of 30-day mortality (OR = 0.61, P = .16) and major postoperative complications (OR = 0.60, P = .06). Regarding the long-term outcomes, EBD was associated with lower risks of seeding metastasis (OR = 0.46, P = .0004) and 5-year recurrence (OR = 0.72, P = .010), and better 5-year survival (OR = 1.62, P = .001). Conclusions. EBD may be associated with higher procedure-related complications compared with PBD as a preoperative biliary drainage method in patients with Klatskin tumor undergoing curative surgery. The available evidence on long-term oncological and survival outcomes are subject to confounding by indication, and high-quality randomized controlled trials are required for definite conclusions.

A279 EUS-GUIDED BILIARY DRAINAGE IN MALIGNANT DISTAL BILIARY OBSTRUCTION: AN INTERNATIONAL SURVEY TO IDENTIFY BARRIERS OF TECHNOLOGY IMPLEMENTATION

Abstract Background Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a promising alternative to endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction (MDBO). Recent small randomized controlled trials comparing EUS-BD with ERCP suggest that EUS-BD achieves a similar technical success rate and safety profile while potentially being associated with lower rates of stent dysfunction However, its application in clinical practice has been impeded by various undefined barriers. Aims To evaluate the current practice of EUS-BD and the determinants for its clinical implementation in MDBO. Methods An online survey was generated using Google Forms. Five endoscopy societies have distributed the survey as of October 10th, 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers to implementation. Descriptive statistics were calculated using frequencies, chi-square statistics were used for inferential analysis, and a standard step-wise multivariable analysis was performed to identify independent variables for and against the use of EUS-BD. Results To date, 102 physicians have participated in the survey (response rate 7.97%). The majority of participants are from North America (39.2%), Asia (31.4%), and Europe (19.6%). Most participants are gastroenterologists with formal therapeutic endoscopy training (66.7%), though only 28.4% have received EUS-BD training. In unresectable cancer, 85.1% of respondents favoured EUS-BD over percutaneous biliary drainage following ERCP failure (p&amp;lt;0.0001), while in borderline resectable disease, 72.3% preferred EUS-BD. On multivariable analysis, male gender, formal training in EUS-BD, and unresectable cancer were independent variables for the use of EUS-BD. Conversely, independent discouraging factors for EUS-BD included fear of adverse events, limited high-quality data, lack of local expertise, and inadequate access to EUS technology. Conclusions In this international survey, it appears that EUS-BD is gaining traction, especially in the setting of unresectable disease following ERCP failure. However, barriers to implementation include the lack of high-quality data, fear for adverse events, limited experts in the field, and inadequate access to EUS technology. This suggest the need for high-quality clinical trials, increased endoscopist training in this field, and further technology development in EUS-BD in order to increase its uptake in clinical practice. Funding Agencies None

Abstract No. 581 Percutaneous biliary interventions: national trends, patient characteristics, clinical indications, and outcomes in the United States, 1993 to 2015

to explore the national trends, patient characteristics, clinical indications and outcomes for percutaneous biliary interventions in the United States, 1993 – 2015. Inpatient stays associated with percutaneous transhepatic cholangiogram (PTC), percutaneous extraction of common duct stones and percutaneous biliary drainage (PBD) were studied using the data from the National Inpatient Sample. Patient characteristics, outcomes and primary discharge diagnoses were extracted. The overall rate of inpatient PBDs has modestly increased (0.5% per year) since 1993 while the rate of inpatient PTCs have remained stable. Meanwhile, the rate of percutaneous common duct stone extractions has markedly decreased (-7.8% annual change). In terms of outcomes, there has been a significant decrease in in-hospital mortality (-4.1% for PTC and -4.8% for PBD; P <0.05) and length of stay (-1.2 and -1.5 days for PTC and PBD; P <0.05). Total hospital charge has increased from $14,990 for PTC and $17,478 for PBD to $70,629 and $71,383, respectively (P <0.05) and fewer patients are having routine discharge (-23.5% and -19.5%; P <0.05). Biliary and pancreatic disorders (24.9% for PTC, 33.2% for PBD), malignancy (26.4% for PTC, 26.6% for PBD), postoperative complications (19.1% for PTC, 16.1% for PBD) and sepsis (12.8% for PTC, 10.9% for PBD), were the most common discharge diagnoses. Compared to patients with biliary/pancreatic disorders (including cholecystitis, cholelithiasis, cholangitis, bile duct obstruction and pancreatitis), sepsis and malignancy were associated with increased risk of mortality (Adjusted OR: 5.2 [3.9 – 7.0] for sepsis, 2.3 [1.7 – 3.0] for malignancy), lengthy hospital stay (Adjusted OR: 2.2 [1.9 – 2.5] for sepsis, 1.6 [1.4 – 1.8] for malignancy) and greater total hospital charges (Adjusted OR: 2.4 [2.1 – 2.8] for sepsis, 1.5 [1.4 – 1.7] for malignancy. There has been a significant decrease in mortality, length of stay, and routine disposition among patients undergoing PTC and PBD, while the hospital charges have steadily increased in the past two decades. Sepsis and malignancy were the two main determinants of unfavorable outcomes.

3:45 PM Abstract No. 104 Percutaneous management of biliary strictures following orthotopic liver transplantation: long-term outcomes analysis

To retrospectively evaluate long-term outcomes following percutaneous biliary drainage (PBD) for treatment of posttransplant biliary stricture. Patients with posttransplant biliary stricture managed with an institutional protocol of PBD placement, serial drain upsize and cholangioplasty were reviewed. Biliary drains were removed if cholangiogram demonstrated unobstructed biliary flow, and liver function tests remained stable after placement of an end-hole 5Fr catheter. Stricture patency rates following drain removal were estimated using the Kaplan-Meier method and compared between groups using the Log-rank test. Cox regression analysis was performed to identify predictors of recurrent biliary stricture. 25 patients (15 males, 10 females) were identified for analysis. Patients with primary sclerosing cholangitis comprised the largest subgroup (n = 13, 52%). 40% (n = 10) had anastomotic strictures, 44% (n = 11) had non-anastomotic strictures, and 16% (n = 4) had multifocal strictures. 68% (n = 17) had a single drain, 28% (n = 7) had two drains, and 4% (n = 1) had three or more drains. 44% (n = 11) underwent failed endoscopic treatment prior to PBD. The median duration of biliary drainage was 302 days. 72% patency rate was observed following drain removal at up to 148 months. 8% of patients (n = 2) failed PBD and underwent surgical revision (n = 1) or re-transplant (n = 1). Following drain removal, 20% (n = 5) developed repeat biliary stricture necessitating re-intervention (repeat PBD, n = 4 and repeat transplant, n = 1). Significantly decreased stricture patency was observed for patients requiring multiple vs. single drain (P = 0.034). In univariate analysis, larger final drain size (HR: 0.21, P = 0.027) was associated with lower hazards of drain failure while increased drain dwell time was associated with a higher hazard of drain failure (HR: 1.09, P = 0.020). Percutaneous management of posttransplant biliary stricture provided long-term stricture patency in 72% of patients. Repeat transplant or surgery was needed in 12%. Larger final drain size and increased drain dwell time are associated with higher and lower patency rates, respectively.

3:27 PM Abstract No. 102 Infectious complications and postprocedural antibiotics following initial percutaneous biliary drainage for patients with endoscopically placed stents

To evaluate the risk of cholangitis and role of postprocedural antibiotics for patients with endoscopic biliary stents (EBS) undergoing initial percutaneous biliary cholangiography and drainage (PTC). Retrospective review identified all adult patients undergoing initial PTC without preprocedural evidence of cholangitis over an 18-month period at a large academic center. Cholangitis was defined as fever ≥ 38.5°C within 24 hours of the PTC. Clinical characteristics between patients with and without EBS were compared using chi-squared. 64 patients with a mean age of 62 were included; all patients received preprocedural prophylactic antibiotics. 60 (94%) patients presented with biliary obstruction and 4 (6%) with biliary leak. 45 patients (70%) had a history of endoscopic retrograde cholangiopancreatography (ERCP), 23 (36%) had EBS, and 28 (44%) had a surgical bilioenteric anastomosis. Overall, 9 patients (14%) became cholangitic with one patient developing septic shock. Patients with EBS were more likely to develop cholangitis compared to both the entire cohort (7/23 vs. 2/41, P = 0.005) and patients with history of ERCP alone (7/23 vs. 1/19, P = 0.02). 22 (34.4%) patients were placed on postprocedural empiric antibiotics (i.e., antibiotics without clinical evidence of cholangitis) by their primary team. 6 patients with EBS were placed on empiric post procedure antibiotics and none developed cholangitis, whereas 7 of the 17 (41.2%) not placed on empiric antibiotics developed cholangitis (P = 0.059). These results suggest that patients with EBS may be at high-risk for developing cholangitis after initial PTC beyond the risk conferred to patients with previous ERCP. This may be due to the presence of an indwelling foreign body. The role of routine postprocedural empiric antibiotics for this patient group needs further investigation given the high morbidity associated with cholangitis.

3:36 PM Abstract No. 103 Percutaneous biliary drainage for malignant biliary obstruction to enable cancer therapy: how many patients actually make it to treatment?

3:36 PM Abstract No. 103 Percutaneous biliary drainage for malignant biliary obstruction to enable cancer therapy: how many patients actually make it to treatment?

Chemotherapy: Knowing When to Start, Evaluate for Response, and Stop

Chemotherapy is essential treatment in pancreatobiliary cancer patients. Knowing optimal time of chemotherapy initiation is important. Usually good performance status and general condition without jaundice is first recommendation for initiating chemotherapy. Good performance status is defined as Eastern Cooperative Oncology Group 0-1, with good biliary drainage and adequate nutritional intake. Percutaneous or endoscopic biliary drainage is recommended before chemotherapy in patient who shows high bilirubin level. The optimal timing of chemotherapy after diagnosis is not standardized but guideline recommends chemotherapy less 2 months after initial cancer diagnosis. Regard to chemotherapy response evaluation, Response Evaluation Criteria in Solid Tumors criteria is used per 2-3 months. Response Evaluation Criteria in Solid Tumors criteria evaluate the chemotherapy responsiveness. With regular tumor response, clinicians must determine whether patient can undergo chemotherapy continuously without complication. For example, Eastern Cooperative Oncology Group 3 or poor general condition make patient not to undergo chemotherapy and focus on end-of-life care. As a result, knowing about the start and stop of chemotherapy can help relieve the patient's symptoms, prolong survival and improve the quality of life.