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Mo1247 EUS-Guided Pancreaticogastrostomy and Pancreaticoduodenostomy: Safety and Efficacy Evaluation
Abstracts
Mo1247 EUS-Guided Pancreaticogastrostomy and Pancreaticoduodenostomy: Safety and Efficacy Evaluation Juan J. Vila*1, Manuel Perez-Miranda2, Joan B. Gornals3, Enrique Vazquez-Sequeiros4, Jose Ramon Aparicio5, Ignacio Fernandez-Urien1, Marta Cimavilla2, Ramon Sanchez-Ocana2, Claudia F. Consiglieri3, Juan Carrascosa1, Carlos De la Serna2 1 Endoscopy Unit. Gastroenterology Dpt., Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain; 2Endoscopy Unit. Gastroenterology Dpt., Hospital Rio-Hortega, Valladolid, Spain; 3 Endoscopy Unit. Gastroenterology Dpt., Hospital Bellvitge, Barcelona, Spain; 4Endoscopy Unit. Gastroenterology Dpt., Hospital Ramón y Cajal, Madrid, Spain; 5Endoscopy Unit. Gastroenterology Dpt, Hospital General Universitario de Alicante., Alicante, Spain Background: EUS-guided pancreaticogastrostomy (EUS-PG) and pancreaticoduodenostomy (EUS-PD) allow transmural drainage of the pancreatic duct when transpapillary drainage is not feasible. These minimally invasive procedures are risky and technically demanding and must be reserved to expert endoscopists. Aim: To evaluate technical and clinical outcomes of EUS-PG/PD and parameters related to technical and clinical success. Method: Retrospective analysis of a prospective database including the experience in EUS-PG/PD of 5 university hospitals during the last 6 years. Variables included: epidemiological data, indication, technique, postprocedure clinical evolution, early and late complications. During follow up patients were classified in Group A when a scheduled exchange of the stent was performed irrespective of the clinical situation and Group B when the stent exchange was only scheduled when they became symptomatic. Technical success was considered when a stent was inserted connecting the pancreatic duct with the gastric or duodenal lumen. Clinical success was considered when the symptoms were resolved. Early and late complications were defined as those occurring in or after the first month after the procedure respectively. Comparisons were made using Chi-square test. Approval by the leading hospital ethics committee was obtained. Results: 27 patients were included (mean age: 53.6 years). Indication for EUS-PG/EUS-PD was: pancreatic stenosis (23 patients), disconnected duct (3 patients) and pancreaticocutaneous fistula (1 patient). Pancreatic type pain was the main symptom in 92% of patients. Technical success was achieved in 85% of patients, performing 20 EUS-PG and 3 EUS-PD. Early complications appeared in 15% of patients: abdominal pain (2), pancreatitis (1) and pancreatic collection (1). Late complications occurred in 19% of patients: stent occlusion (1), pancreatic stones (1), stent migration (2) and cystic neumatosis (1). All complications were managed conservatively or with endoscopic treatment. Interestingly, all EUS-PD developed a complication compared with only 10 % of EUS-PG. Clinical success was achieved in 95% of patients with technical success, 81% overall. During follow up (mean: 21.8 months) 9 patients were included in Group A and 14 in Group B. Scheduled stent endoscopic exchange was performed in 100% of patients in Group A while 14% of patients in Group B required stent exchange (p<0.05). No significant differences were seen regarding mean follow up (26.2 vs 18.6 months, p>0.05), clinical success (89% vs 100%, p>0.05) or late complication rate (33% vs 7%, p>0.05) between Group A and B. Conclusions: EUS-PG/PD has a technical success of 85% with 95% clinical success. Our data suggest a higher complication rate with EUS-PD and that scheduled stent exchange is not required and should only be made according to clinical situation.
Mo1248 Management of Walled Off Pancreatic Necrosis: Skin or Scope Ankush R. Pawar*, Amol S. Dahale, Siddharth Srivastava, Sanjeev Sachdeva, Sundeep Saluja, Poonam Narang Gastroenterology, G B Pant Hospital, GIPMER, Delhi, DELHI, India Background and Aims: Walled of pancreatic necrosis (WON) is a local complication in late phase of severe acute pancreatitis. With advent of minimally invasive therapies over last few decades like percutaneous and endoscopic drainage, paradigm shift has occurred in management of WON. Surgery which was the mainstay in the past is considered now as a salvage therapy. There is a scarcity of data comparing endoscopic guided drainage versus percutaneous drainage in WON. Methods: We evaluated all patients with WON from September 2015 to October 2016. All patients were treated as per our institutional protocol. Percutaneous drainage and endoscopic ultrasound guided metallic stent placement were used as minimally invasive therapies for drainage whenever required. Surgery used as a salvage therapy. We compared data of patients who underwent percutaneous drainage versus those who
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underwent endoscopic ultrasound guided metallic stent placement. We assessed demographical profile, etiology, length of hospital stay, mortality and complications in both groups. Results: Total 219 patients of acute pancreatitis admitted during study period, of these 80(37%) patients had symptomatic WON. Out of total symptomatic WON 35(44%) patients managed conservatively while 45(56%) patients required intervention. Per-cutaneous drainage (PCD), EUS guided SEMS and combination of both was done in 25(56%), 17(38%) and 3(6%) patients respectively. We compared 25 patients from PCD group with 17 patients from SEMS group. Those treated with combination therapy were excluded from analysis. Demographic profile, etiology and lab parameters were comparable between both the groups at baseline (pZ NS). Length of hospital stay was significantly less in EUS guided drainage group (mean:97.5 days, range 1-28days) as compared to percutaneous drainage group (mean:27 21 days, range2-88 days, p-Value <0.05). 4(16%) patients in PCD group developed cystocutaneous fistula as an adverse event while 1(6%) patient had stent migration in endoscopic group. Though trends of adverse events were higher in percutaneous group they did not reach to a significant value (16% vs 6%, p-0.3) 3 patients died in PCD group and 1 in SEMS group (p-NS) Conclusion: EUS guided SEMS in management of WON is safe and effective modality. EUS guided SEMS has shorter length of hospital stay and fewer complications as compared to percutaneous drainage.
Mo1249 Comparison of Outcomes in Patients at High Risk for Recurrent Gastroesophageal Variceal Bleeding Treated by EUS-Guided Cyanoacrylate Injection for Secondary Prophylaxis or Conventional Endoscopic Cyanoacrylate Injection for Index Bleeding Alone Raymond S. Tang*1, John C. Wong1, Moe H. Kyaw1, Anthony Y. Teoh2, Yee Kit Tse1, Thomas Y. Lam1, Justin C. Wu1, James Y. Lau2 1 Institute of Digestive Disease, Chinese University of Hong Kong, Kowloon Tong, Hong Kong; 2Department of Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong Background: Patients with hepatocellular carcinoma (HCC) or other malignancies +portal vein thrombosis (PVT) are at high risk for recurrent variceal bleeding. Rebleeding rate remains high (28 - 42%) in patients with HCC and esophageal variceal (EV) bleeding treated by endoscopic cyanoacrylate (CYA) injection or band ligation. Recent evidence suggested secondary prophylaxis (SP) for variceal bleeding may improve outcomes in patients with HCC, but the optimal approach is not well defined. This study aims to compare outcomes in patients at high risk for recurrent gastroesophageal variceal bleeding treated by EUS-guided CYA injection for SP and conventional CYA injection for index bleeding alone. Methods: From 2014-2016, consecutive patients with HCC+/-PVT, or non-HCC malignancy+PVT presenting with gastroesophageal variceal bleeding within 12 weeks were recruited for EUS-CYA for SP. EV and GV were assessed on EUS for size and vascular flow. Varices 3mm were treated by EUS-CYA via a 19G needle with linear echoendoscope. Doppler was used for real-time confirmation of variceal obliteration. Patients were followed for 6 months after EUS or till death, with follow-up EUS at day 90 and 180. A historical control group of HCC patients who underwent conventional EGD-CYA for index GV or EV bleeding alone was identified in a prospective GI bleed database from 20092013 for comparison. Outcome measures are death-adjusted cumulative incidence of rebleeding at 30-day and 90-day, and procedure related complications. Results: 23 patients (mean age 64+/-9; 87.0% male) underwent EUS-CYA for SP during the study period, while 33 HCC patients (mean age 59+/-10, 90.9% male) who underwent EGD-CYA for index GV or EV bleeding alone were identified as historical controls. In the EUS-CYA for SP group, 20 patients had HCC+cirrhosis (85.0% also with PVT), while the other 3 patients had non-HCC malignancy+PVT. Majority of the HCC patients in the EUS-CYA for SP group and the EGD-CYA control group had Barcelona Clinic Liver Cancer (BCLC) stage C disease (85.0% vs 75.8%, pZ0.421) and ChildPugh class B cirrhosis (55.0% vs 71.4%, pZ0.241). 13 OV, 6 GV, and 4 OV+GV were treated by EUS-CYA for SP. 52.2% of patients in the EUS-CYA for SP group had varices 5mm on EUS. Both the 30-day and 90-day death adjusted cumulative incidence of rebleeding were significantly lower in the EUS-CYA for SP group when compared to EGD-CYA control group (13% vs 42% at 30-day, pZ0.023 and 22% vs 61% at 90-day, pZ0.005, respectively). No pulmonary CYA embolism (as indicated by lipiodol on chest x-ray) was found in either group. Conclusion: In this study, EUSCYA for SP was found to significantly reduce both the 30-day and 90-day death adjusted cumulative incidence of rebleeding in patients at high risk for recurrent gastroesophageal variceal bleeding when compared to EGD-CYA for index bleeding alone.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB475
Mo1247 EUS-Guided Pancreaticogastrostomy and Pancreaticoduodenostomy: Safety and Efficacy Evaluation Juan J. Vila*1, Manuel Perez-Miranda2, Joan B. Gornals3, Enrique Vazquez-Sequeiros4, Jose Ramon Aparicio5, Ignacio Fernandez-Urien1, Marta Cimavilla2, Ramon Sanchez-Ocana2, Claudia F. Consiglieri3, Juan Carrascosa1, Carlos De la Serna2 1 Endoscopy Unit. Gastroenterology Dpt., Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain; 2Endoscopy Unit. Gastroenterology Dpt., Hospital Rio-Hortega, Valladolid, Spain; 3 Endoscopy Unit. Gastroenterology Dpt., Hospital Bellvitge, Barcelona, Spain; 4Endoscopy Unit. Gastroenterology Dpt., Hospital Ramón y Cajal, Madrid, Spain; 5Endoscopy Unit. Gastroenterology Dpt, Hospital General Universitario de Alicante., Alicante, Spain Background: EUS-guided pancreaticogastrostomy (EUS-PG) and pancreaticoduodenostomy (EUS-PD) allow transmural drainage of the pancreatic duct when transpapillary drainage is not feasible. These minimally invasive procedures are risky and technically demanding and must be reserved to expert endoscopists. Aim: To evaluate technical and clinical outcomes of EUS-PG/PD and parameters related to technical and clinical success. Method: Retrospective analysis of a prospective database including the experience in EUS-PG/PD of 5 university hospitals during the last 6 years. Variables included: epidemiological data, indication, technique, postprocedure clinical evolution, early and late complications. During follow up patients were classified in Group A when a scheduled exchange of the stent was performed irrespective of the clinical situation and Group B when the stent exchange was only scheduled when they became symptomatic. Technical success was considered when a stent was inserted connecting the pancreatic duct with the gastric or duodenal lumen. Clinical success was considered when the symptoms were resolved. Early and late complications were defined as those occurring in or after the first month after the procedure respectively. Comparisons were made using Chi-square test. Approval by the leading hospital ethics committee was obtained. Results: 27 patients were included (mean age: 53.6 years). Indication for EUS-PG/EUS-PD was: pancreatic stenosis (23 patients), disconnected duct (3 patients) and pancreaticocutaneous fistula (1 patient). Pancreatic type pain was the main symptom in 92% of patients. Technical success was achieved in 85% of patients, performing 20 EUS-PG and 3 EUS-PD. Early complications appeared in 15% of patients: abdominal pain (2), pancreatitis (1) and pancreatic collection (1). Late complications occurred in 19% of patients: stent occlusion (1), pancreatic stones (1), stent migration (2) and cystic neumatosis (1). All complications were managed conservatively or with endoscopic treatment. Interestingly, all EUS-PD developed a complication compared with only 10 % of EUS-PG. Clinical success was achieved in 95% of patients with technical success, 81% overall. During follow up (mean: 21.8 months) 9 patients were included in Group A and 14 in Group B. Scheduled stent endoscopic exchange was performed in 100% of patients in Group A while 14% of patients in Group B required stent exchange (p<0.05). No significant differences were seen regarding mean follow up (26.2 vs 18.6 months, p>0.05), clinical success (89% vs 100%, p>0.05) or late complication rate (33% vs 7%, p>0.05) between Group A and B. Conclusions: EUS-PG/PD has a technical success of 85% with 95% clinical success. Our data suggest a higher complication rate with EUS-PD and that scheduled stent exchange is not required and should only be made according to clinical situation.
Mo1248 Management of Walled Off Pancreatic Necrosis: Skin or Scope Ankush R. Pawar*, Amol S. Dahale, Siddharth Srivastava, Sanjeev Sachdeva, Sundeep Saluja, Poonam Narang Gastroenterology, G B Pant Hospital, GIPMER, Delhi, DELHI, India Background and Aims: Walled of pancreatic necrosis (WON) is a local complication in late phase of severe acute pancreatitis. With advent of minimally invasive therapies over last few decades like percutaneous and endoscopic drainage, paradigm shift has occurred in management of WON. Surgery which was the mainstay in the past is considered now as a salvage therapy. There is a scarcity of data comparing endoscopic guided drainage versus percutaneous drainage in WON. Methods: We evaluated all patients with WON from September 2015 to October 2016. All patients were treated as per our institutional protocol. Percutaneous drainage and endoscopic ultrasound guided metallic stent placement were used as minimally invasive therapies for drainage whenever required. Surgery used as a salvage therapy. We compared data of patients who underwent percutaneous drainage versus those who
www.giejournal.org
underwent endoscopic ultrasound guided metallic stent placement. We assessed demographical profile, etiology, length of hospital stay, mortality and complications in both groups. Results: Total 219 patients of acute pancreatitis admitted during study period, of these 80(37%) patients had symptomatic WON. Out of total symptomatic WON 35(44%) patients managed conservatively while 45(56%) patients required intervention. Per-cutaneous drainage (PCD), EUS guided SEMS and combination of both was done in 25(56%), 17(38%) and 3(6%) patients respectively. We compared 25 patients from PCD group with 17 patients from SEMS group. Those treated with combination therapy were excluded from analysis. Demographic profile, etiology and lab parameters were comparable between both the groups at baseline (pZ NS). Length of hospital stay was significantly less in EUS guided drainage group (mean:97.5 days, range 1-28days) as compared to percutaneous drainage group (mean:27 21 days, range2-88 days, p-Value <0.05). 4(16%) patients in PCD group developed cystocutaneous fistula as an adverse event while 1(6%) patient had stent migration in endoscopic group. Though trends of adverse events were higher in percutaneous group they did not reach to a significant value (16% vs 6%, p-0.3) 3 patients died in PCD group and 1 in SEMS group (p-NS) Conclusion: EUS guided SEMS in management of WON is safe and effective modality. EUS guided SEMS has shorter length of hospital stay and fewer complications as compared to percutaneous drainage.
Mo1249 Comparison of Outcomes in Patients at High Risk for Recurrent Gastroesophageal Variceal Bleeding Treated by EUS-Guided Cyanoacrylate Injection for Secondary Prophylaxis or Conventional Endoscopic Cyanoacrylate Injection for Index Bleeding Alone Raymond S. Tang*1, John C. Wong1, Moe H. Kyaw1, Anthony Y. Teoh2, Yee Kit Tse1, Thomas Y. Lam1, Justin C. Wu1, James Y. Lau2 1 Institute of Digestive Disease, Chinese University of Hong Kong, Kowloon Tong, Hong Kong; 2Department of Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong Background: Patients with hepatocellular carcinoma (HCC) or other malignancies +portal vein thrombosis (PVT) are at high risk for recurrent variceal bleeding. Rebleeding rate remains high (28 - 42%) in patients with HCC and esophageal variceal (EV) bleeding treated by endoscopic cyanoacrylate (CYA) injection or band ligation. Recent evidence suggested secondary prophylaxis (SP) for variceal bleeding may improve outcomes in patients with HCC, but the optimal approach is not well defined. This study aims to compare outcomes in patients at high risk for recurrent gastroesophageal variceal bleeding treated by EUS-guided CYA injection for SP and conventional CYA injection for index bleeding alone. Methods: From 2014-2016, consecutive patients with HCC+/-PVT, or non-HCC malignancy+PVT presenting with gastroesophageal variceal bleeding within 12 weeks were recruited for EUS-CYA for SP. EV and GV were assessed on EUS for size and vascular flow. Varices 3mm were treated by EUS-CYA via a 19G needle with linear echoendoscope. Doppler was used for real-time confirmation of variceal obliteration. Patients were followed for 6 months after EUS or till death, with follow-up EUS at day 90 and 180. A historical control group of HCC patients who underwent conventional EGD-CYA for index GV or EV bleeding alone was identified in a prospective GI bleed database from 20092013 for comparison. Outcome measures are death-adjusted cumulative incidence of rebleeding at 30-day and 90-day, and procedure related complications. Results: 23 patients (mean age 64+/-9; 87.0% male) underwent EUS-CYA for SP during the study period, while 33 HCC patients (mean age 59+/-10, 90.9% male) who underwent EGD-CYA for index GV or EV bleeding alone were identified as historical controls. In the EUS-CYA for SP group, 20 patients had HCC+cirrhosis (85.0% also with PVT), while the other 3 patients had non-HCC malignancy+PVT. Majority of the HCC patients in the EUS-CYA for SP group and the EGD-CYA control group had Barcelona Clinic Liver Cancer (BCLC) stage C disease (85.0% vs 75.8%, pZ0.421) and ChildPugh class B cirrhosis (55.0% vs 71.4%, pZ0.241). 13 OV, 6 GV, and 4 OV+GV were treated by EUS-CYA for SP. 52.2% of patients in the EUS-CYA for SP group had varices 5mm on EUS. Both the 30-day and 90-day death adjusted cumulative incidence of rebleeding were significantly lower in the EUS-CYA for SP group when compared to EGD-CYA control group (13% vs 42% at 30-day, pZ0.023 and 22% vs 61% at 90-day, pZ0.005, respectively). No pulmonary CYA embolism (as indicated by lipiodol on chest x-ray) was found in either group. Conclusion: In this study, EUSCYA for SP was found to significantly reduce both the 30-day and 90-day death adjusted cumulative incidence of rebleeding in patients at high risk for recurrent gastroesophageal variceal bleeding when compared to EGD-CYA for index bleeding alone.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB475