- Email: [email protected]
1109 Impact of EUS-FNA From Peritoneal Lesions for Avoiding Diagnostic Laparoscopy (Ipad Study): The First Prospective Study (Preliminary Results)
Abstracts
(AE severity: moderate nZ3 and severe nZ1). AE rates were comparable between the two cohorts (DGE 5.5% vs. BAGE 5.9% pZ1.00). Post-procedure length of stay, need for re-intervention, and survival were also comparable between the two cohorts. Conclusion: This is the largest study on EUS-GE to date and suggests DGE as the more efficient technique. Nonetheless, both DGE and BAGE are effective and safe procedures when performed by experienced operators.
1109 The Use of Angiography as a Modification of the Eus-Guided Injection of Cyanoacrylate With Coils Technique for Gastric Varices Treatment Carlos Robles-Medranda*, Manuel Valero, Miguel Puga-Tejada, Miguel Soria ALcívar, Guillermo Muñoz Jurado, Jesenia Ospina, Hannah P. Lukashok Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Guayas, Ecuador Background: Bleeding from gastric varices (GV) is a severe complication and the mortality associated is high. Treatment with cyanoacrylate (CYA) glue injection has demonstrated higher hemostasis (>90%) and lower rebleeding rates compared to band ligation or sclerotherapy. Currently CYA can be injected alone or in combination with coils under Endoscopic Ultrasound (EUS) guidance with the benefit of precise targeting of the varix lumen. The performance of an angiography guided by EUS and under fluoroscopy evaluation, represents a modification to the original technique that add some benefits. The injection of water-soluble contrast allows identifying the variceal flow and the afferent feeding vessel, with less number of coils and volume of CYA needed for its obliteration. Also if there is a shunt (a common reason for procedure failure) it can be seen and the injection of CYA into the splenic vein or artery can be avoided. In case of active bleeding the angiography allows visualizing which varix is bleeding, and target the injection. Patients and Method: From July 2015 to November 2016 a total of 24 patients with GV (16 with GOV type II and 8 with IGV type I), with a mean age of 62.3 (range 44-76) years old, were treated with EUS injection of coils + CYA for active bleeding management in 8 (33.3%) patients, primary prophylaxis in 2 (8.3%) and secondary prophylaxis in 14 (58.3%). The average size of varices was 19.7 mm (12-32 mm), the average number of coils used was 2 (1-3) and the average volume of CYA was 1.54 ml (1.2-2.4 ml). The procedure success was 100%. There were no episodes of rebleeding in a 10 months follow-up and the complication rate was 8.3% (1 episode of fever and 1 case of abdominal pain). Conclusion and Clinical Implication: The EUS-angiography is a safe procedure and adds benefits to the original technique of EUS-guided injection of CYA with coils for GV treatment.
1108 Compilation of EUS Imaging Demonstrating Variant Pancreatic Ductal Anatomy With Radiologic Corroboration and Motion Animation Matheus C. Franco*, Amit Bhatt, Abhik Bhattacharya, Prabhleen Chahal Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH Background and Aim: Congenital anatomic variants of the pancreatic duct are rare. Variant anatomy may be discovered incidentally or it may cause a wide range of symptoms. Presentation may include acute pancreatitis, chronic pancreatitis, choledochal cyst, and certain variant pancreatic ductal anatomy have been shown to increase the risk of hepatobiliary malignancy. Endoscopic ultrasound (EUS) is a minimally invasive diagnostic test for anatomic variants in the pancreatic duct. The aim of this novel video effort is to elucidate EUS images demonstrating three different variants of the pancreatic ductal anatomy with the radiologic corroboration and motion animation. Cases description: The first case is a 48-year-old female with history of chronic abdominal pain and idiopathic recurrent acute pancreatitis. She had persistent symptoms after cholecystectomy, and was on chronic narcotics. Outside MRI and labs were unrevealing for cause. EUS evaluation showed a dominant dorsal pancreatic duct (PD) draining into the minor papilla, compatible with pancreas divisum. Repeat MRI with secretin confirmed the diagnosis of pancreas divisum. Patient underwent ERCP with minor papilla sphincterotomy and balloon sphincteroplasty. She had complete relief of pain without recurrent pancreatitis episode at her one year follow up. Second case is a 52 year-old female, with chronic vague upper abdominal pain. Her review of systems was otherwise remarkable. Investigations revealed normal liver blood tests, EGD and CT scan. Patient was referred for EUS evaluation. EUS showed an anomalous junction between pancreatic duct and bile duct located outside the duodenal wall, resulting in a long common channel. MRI confirmed the findings observed by EUS. Due to the higher risk of gallbladder cancer associated with pancreatobiliary maljunction, prophylactic cholecystectomy was recommended. The last case is a 75 year-old female, with known history of asymptomatic side-branch IPMN. Follow-up imaging with MRI revealed a bifid pancreatic dust arising from the body of pancreas. This finding was also well observed and illustrated with EUS evaluation. There is no relevant clinical significance related with bifid PD reported in the literature, patient continues to have imaging surveillance of side-branch IPMN. Conclusions: Even though MRI is an accurate diagnostic test for anatomic variants in the pancreas, as illustrated in these cases, some patients may be misdiagnosed. EUS is a safe and reliable minimally invasive choice for diagnosing variant pancreatic ductal anatomy.
AB142 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
1109 Impact of EUS-FNA From Peritoneal Lesions for Avoiding Diagnostic Laparoscopy (Ipad Study): The First Prospective Study (Preliminary Results) Sirilak Yooprasert*1, Pradermchai Kongkam1, Wiriyaporn Ridtitid1, Piyapan Prueksapanich1, Sombat Treeprasertsuk1, Pinit Kullavanijaya1, Duangpen Thirabanjasak2, Rungsun Rerknimitr1 1 Internal medicine, Division of gastroenterology King chulalongkorn memorial hospital, Bangkok, Bangkok, Thailand; 2Pathology, Chulalongkorn University, Bangkok, Bangkok, Thailand Introduction: In patients with undiagnosed peritoneal diseases, diagnostic laparoscopy is often required to achieve a diagnosis but it is an invasive method to obtain tissue. For less invasive modality, endoscopic ultrasonography guided fine needle aspiration(EUS-FNA) is feasible for tissue acquisition. It is interesting to know efficacy of EUS-FNA for avoiding diagnostic laparoscopy in a prospective fashion. Aim: To study the efficacy of EUS-FNA for avoiding diagnostic laparoscopy in patients with peritoneal lesions. Methods: From December 2015 to October 2016, all consecutive patients with peritoneal lesions identified by CT at King Chulalongkorn Memorial Hospital, Bangkok, Thailand were enrolled into the study. Exclusion criteria were uncorrectable coagulopathy, pregnancy and age less than 18 years-old. EUS-FNA of peritoneal lesions was performed in all patients. Diagnostic laparoscopy was planned if pathological result of EUS-FNA was negative. Avoidance rate for diagnostic laparoscopy as a consequence of EUS-FNA was calculated. Results: Eighteen patients (9M; mean age+/- SD 60.9+/-14.7 years) were enrolled into the IPAD study. Presenting symptoms were weight loss (nZ18; 100%), jaundice (nZ8; 66.7%), abdominal distension (nZ5; 41.7%) and abdominal pain (nZ7; 38.9%). CT findings were soft tissue nodules/mass deposit in peritoneum (nZ13; 72.2%), ascites (nZ12; 66.7%), omental cake appearance (nZ6; 33.3%) and stranding of mesentery (nZ3; 16.7%). Final diagnoses were shown in table 1. Two benign cases were pancreatic ascites confirmed by laparoscopy and peritoneal tuberculosis confirmed by successful treatment. EUS-FNA showed positive results of malignancy in 14/18 patients (77.8%) and 28/54 passes (51.8%). Of 28 passes with positive results, 22/28 (78.6%) and 6/28 (21.4%) were obtained from hypoechoic peritoneal lesions and hyperechoic omental cake lesions, respectively. Interestingly, in 2 patients with benign peritoneal diseases, EUS revealed only thickening hyperechoic omental cake without hypoechoic peritoneal nodules. No adverse events were observed. Of 4 patients with negative results of EUS-FNA, 2 patients underwent diagnostic laparoscopy showing multiple omental and peritoneal nodules from metastatic gastric cancer (nZ1) and pancreatic ascites (nZ1); another 2 patients refused laparoscopy; one had advanced staged pancreatic cancer with poor performance status and another was clinically diagnosed as peritoneal tuberculosis with successful treatment. The sensitivity and specificity of EUS-FNA from peritoneal lesions were 87.5% and 100%, respectively. Based on results of EUS-FNA, diagnostic laparoscopy can be avoided in 14/18 (77.8%) patients (Table 2). Conclusions: In this prospective study,
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Abstracts
EUS-FNA has a high sensitivity rate for diagnosing causes peritoneal lesions and can avoid diagnostic laparoscopy in majority of patients.
Table 1: Demographic data of patients underwent EUS-FNA from peritoneal lesions EUS-FNA (n[18)
Data Male (n (%)) Age (year S.D.) Presenting symptoms
CT scan findings
EUS findings of peritoneal lesions
Final diagnosis
Weight loss jaundice Abdominal distension Abdominal pain Soft tissue nodules/mass deposit in peritoneum Ascites Omental cake appearance Stranding of mesentery Ascites Hypoechoic nodules deposit in peritoneum or omentum Thickening hyperechoic omental cake Pancreatic cancer Gallbladder Primary peritoneal carcinoma Gynecological cancer Bile duct cancer Colorectal cancer Gastric cancer Benign disease
9/18 (50%) 60.914.7 18/18 (100%) 10/18 (55.6%) 9/18 (50%) 7/18 (38.9%) 13/18 (72.2%) 12/18 (66.7%) 6/18 (33.3%) 3/18 (16.7%) 12/18 (66.7%) 11/18 (61.1%) 10/18 (55.6%) 6/18 (33.3%) 3/18 (16.7%) 2/18 (11.5%) 2/18 (11.1%) 1/18 (5.6%) 1/18 (5.6%) 1/18 (5.6%) 2/18 (11.1%)
procedures) and infection (12 studies; 10 events in 439 procedures) were 7.1%[95% CI (4.2 - 11.8)], 2.3%[95% CI (1.2 - 4.4)], 2.2%[95% CI (1.1 - 4.3)], 2%[95% CI (1.0 3.9)], 3.6%[95% CI (2.1 - 5.9)] respectively. In the studies that specifically reported clinical success with EUS-PDD as an outcome (10 studies; 265 events in 356 procedures), the clinical success rate was 70.3%[95% CI (54.9 - 82.2)]. There was substantial heterogeneity in the analysis of technical success rate and overall adverse events rate, which can be explained by subgroup analysis based on study location (Table 1). The technical success rate of EUS-PDD in the 4 studies that had an exclusive study population of post –Whipple surgery patients was 81.5%[95% CI (65.1 - 91.2)]. Conclusions: With a pooled technical success rate of 77%, EUS-PDD appears to be a promising alternative approach for PD decompression in patients who failed conventional ERCP. Among the EUS-PDD related adverse events, pancreatitis (7%) appears to be the most common. The high rate of overall adverse events highlights the importance of referring these procedures to high volume centers with more experience.
Subgroup analysis of success and post procedural complication rates Subgroups TECHNICAL SUCCESS Manuscript
No of studies
Rate (95% CI)
Subgroups
No of studies
Rate (95% CI)
13 9
77.7% (69.3 - 84.4) 75.9% (64.5 - 84.5)
BLEEDING Manuscript
12 9
2.3% (1.2 - 4.4) 2.8% (1.3 - 6.0)
Abstract
4
81.3% (66.3 - 90.6)
Abstract
3
1.2% (0.3 - 4.6)
North America
4
70.0% (57.0 - 80.5)
North America
4
1.8% (0.4 - 6.9)
Europe
4
73.6% (59.5 - 84.1)
Europe
4
4.0% (1.4 - 10.9)
Asia
2
72.1% (46.8 - 88.4)
Asia
1
2.8% (0.2 - 32.2)
Others
3
89.7% (81.9 - 94.3)
Others
3
1.2% (0.4 - 4.2)
CLINICAL SUCCESS
10
70.3% (54.9 - 82.2)
PERFORATION
12
2.2% (1.1 - 4.3)
Manuscript
7
60.4% (44.5 - 74.4)
Manuscript
9
2.7% (1.2 - 5.7)
Abstract
3
88.2% (73.0 - 95.4)
Abstract
3
1.2% (0.3 - 4.6)
North America
2
44.1% (23.5 - 67.0)
North America
4
1.8% (0.4 - 6.9)
Europe
3
54.0% (35.9 - 71.0)
Europe
4
3.2% (0.9 - 10.4)
Asia
2
85.4% (62.6 - 95.3)
Asia
1
2.8% (0.2 - 32.2)
Others
3
86.9% (76.8 - 93.0)
Others
3
1.8% (0.6 - 5.1)
ALL ADVERSE EVENTS
12
19.3% (13.3 - 27.0)
PANCREATIC LEAK
12
2.0% (1.0 - 3.9)
Manuscript
9
15.4% (9.2 - 24.6)
Manuscript
9
2.3% (1.0 - 5.1)
Abstract
3
26.4% (14.2 - 43.8)
Abstract
3
1.2% (0.3 - 4.6)
North America
4
13.5% (7.1 - 24.2)
North America
4
1.8% (0.4 - 6.9)
Europe
4
17.0% (8.7 - 30.4)
Europe
4
2.2% (0.5 - 8.3)
Asia
1
5.9% (7 - 35.8)
Asia
1
2.8% (0.2 - 32.2)
Others
3
30.2% (19.6 - 43.5)
Others
3
1.8% (0.6 - 5.1)
PANCREATITIS
12
7.1% (4.2 - 11.8)
INFECTION
12
3.6% (2.1 - 5.9)
Manuscript
9
5.6% (2.8 -10.9)
Manuscript
9
3.4% (1.7 - 6.5)
Abstract
3
10.1% (4.4 - 21.4)
Abstract
3
3.8% (1.7 - 8.5)
North America
4
13.6% (7.7 - 22.9)
North America
4
2.1% (0.6 - 7.2)
Europe
4
2.6% (0.8 - 8.9)
Europe
4
2.2% (0.5 - 8.3)
Asia
1
2.8% (0.2 - 32.9)
Asia
1
2.8% (0.2 - 32.2)
Others
3
7.6% (4.2 - 13.3)
Others
3
4.7% (2.4 - 8.7)
Table 2: Diagnostic yield of EUS-FNA from peritoneal lesions Parameters Sensitivity Specificity PPV NPV Accuracy Avoidance rate for diagnostic laparoscopy
Value 87.5% 100% 100% 50% 88.9% 77.8%
1110 Efficacy and Safety of Endoscopic Ultrasound (EUS) Guided Pancreatic Duct Drainage - A Systematic Review and Meta- Analysis Rajesh Krishnamoorthi*1, Mahendran Jayaraj2, Babu Pappu Mohan3, Varun K. Thiagarajan1, Michael C. Larsen1, Andrew S. Ross1, Shayan S. Irani1, Seng-Ian Gan1 1 Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA; 2 University of Nevada School of Medicine, Las Vegas, NV; 3University of Alabama, Tuscaloosa, AL Background: Endoscopic ultrasound (EUS) guided drainage of the pancreatic duct (PD) is a minimally invasive alternative to surgery for decompression of PD in patients who have failed conventional endoscopic retrograde cholangiopancreatography (ERCP) and in patients with altered anatomy. With improvement in EUS technology and specialized training programs in EUS procedures, the practice of EUS guided PD drainage (EUS-PDD) is expected to increase in future. However, there is significant variation in the reported rates of technical success and adverse events associated with EUS-PDD. We performed a systematic review and metaanalysis to estimate the success rate and adverse events (pancreatitis, bleeding, perforation, PD leak and infection). Methods: A comprehensive search of multiple electronic databases and conference proceedings (from inception through October 2016) was performed to identify studies reporting success rates and adverse events associated with EUS-PDD. The primary outcome was to estimate the pooled rate of technical success of EUS-PDD. The secondary outcome was to estimate the rate of EUS-PDD related adverse events. Results: The pooled rate of technical success of EUS-PDD (13 studies reporting a total of 450 procedures) was 77.7% [95% CI (69.3 84.4)] [Forest plot- Figure 1]. The pooled rate of overall adverse events related to EUS-PDD (12 studies; 91 events in 439 procedures) was 19.3% [95% CI (13.3 - 27)]. The pooled rate of individual adverse events - pancreatitis (12 studies; 28 events in 439 procedures), bleeding (12 studies; 5 events in 439 procedures), perforation (12 studies; 4 events in 439 procedures), PD leak (12 studies; 3 events in 439
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Figure 1: Forest plot: Technical success of EUS guided pancreatic duct drainage
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB143
(AE severity: moderate nZ3 and severe nZ1). AE rates were comparable between the two cohorts (DGE 5.5% vs. BAGE 5.9% pZ1.00). Post-procedure length of stay, need for re-intervention, and survival were also comparable between the two cohorts. Conclusion: This is the largest study on EUS-GE to date and suggests DGE as the more efficient technique. Nonetheless, both DGE and BAGE are effective and safe procedures when performed by experienced operators.
1109 The Use of Angiography as a Modification of the Eus-Guided Injection of Cyanoacrylate With Coils Technique for Gastric Varices Treatment Carlos Robles-Medranda*, Manuel Valero, Miguel Puga-Tejada, Miguel Soria ALcívar, Guillermo Muñoz Jurado, Jesenia Ospina, Hannah P. Lukashok Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Guayas, Ecuador Background: Bleeding from gastric varices (GV) is a severe complication and the mortality associated is high. Treatment with cyanoacrylate (CYA) glue injection has demonstrated higher hemostasis (>90%) and lower rebleeding rates compared to band ligation or sclerotherapy. Currently CYA can be injected alone or in combination with coils under Endoscopic Ultrasound (EUS) guidance with the benefit of precise targeting of the varix lumen. The performance of an angiography guided by EUS and under fluoroscopy evaluation, represents a modification to the original technique that add some benefits. The injection of water-soluble contrast allows identifying the variceal flow and the afferent feeding vessel, with less number of coils and volume of CYA needed for its obliteration. Also if there is a shunt (a common reason for procedure failure) it can be seen and the injection of CYA into the splenic vein or artery can be avoided. In case of active bleeding the angiography allows visualizing which varix is bleeding, and target the injection. Patients and Method: From July 2015 to November 2016 a total of 24 patients with GV (16 with GOV type II and 8 with IGV type I), with a mean age of 62.3 (range 44-76) years old, were treated with EUS injection of coils + CYA for active bleeding management in 8 (33.3%) patients, primary prophylaxis in 2 (8.3%) and secondary prophylaxis in 14 (58.3%). The average size of varices was 19.7 mm (12-32 mm), the average number of coils used was 2 (1-3) and the average volume of CYA was 1.54 ml (1.2-2.4 ml). The procedure success was 100%. There were no episodes of rebleeding in a 10 months follow-up and the complication rate was 8.3% (1 episode of fever and 1 case of abdominal pain). Conclusion and Clinical Implication: The EUS-angiography is a safe procedure and adds benefits to the original technique of EUS-guided injection of CYA with coils for GV treatment.
1108 Compilation of EUS Imaging Demonstrating Variant Pancreatic Ductal Anatomy With Radiologic Corroboration and Motion Animation Matheus C. Franco*, Amit Bhatt, Abhik Bhattacharya, Prabhleen Chahal Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH Background and Aim: Congenital anatomic variants of the pancreatic duct are rare. Variant anatomy may be discovered incidentally or it may cause a wide range of symptoms. Presentation may include acute pancreatitis, chronic pancreatitis, choledochal cyst, and certain variant pancreatic ductal anatomy have been shown to increase the risk of hepatobiliary malignancy. Endoscopic ultrasound (EUS) is a minimally invasive diagnostic test for anatomic variants in the pancreatic duct. The aim of this novel video effort is to elucidate EUS images demonstrating three different variants of the pancreatic ductal anatomy with the radiologic corroboration and motion animation. Cases description: The first case is a 48-year-old female with history of chronic abdominal pain and idiopathic recurrent acute pancreatitis. She had persistent symptoms after cholecystectomy, and was on chronic narcotics. Outside MRI and labs were unrevealing for cause. EUS evaluation showed a dominant dorsal pancreatic duct (PD) draining into the minor papilla, compatible with pancreas divisum. Repeat MRI with secretin confirmed the diagnosis of pancreas divisum. Patient underwent ERCP with minor papilla sphincterotomy and balloon sphincteroplasty. She had complete relief of pain without recurrent pancreatitis episode at her one year follow up. Second case is a 52 year-old female, with chronic vague upper abdominal pain. Her review of systems was otherwise remarkable. Investigations revealed normal liver blood tests, EGD and CT scan. Patient was referred for EUS evaluation. EUS showed an anomalous junction between pancreatic duct and bile duct located outside the duodenal wall, resulting in a long common channel. MRI confirmed the findings observed by EUS. Due to the higher risk of gallbladder cancer associated with pancreatobiliary maljunction, prophylactic cholecystectomy was recommended. The last case is a 75 year-old female, with known history of asymptomatic side-branch IPMN. Follow-up imaging with MRI revealed a bifid pancreatic dust arising from the body of pancreas. This finding was also well observed and illustrated with EUS evaluation. There is no relevant clinical significance related with bifid PD reported in the literature, patient continues to have imaging surveillance of side-branch IPMN. Conclusions: Even though MRI is an accurate diagnostic test for anatomic variants in the pancreas, as illustrated in these cases, some patients may be misdiagnosed. EUS is a safe and reliable minimally invasive choice for diagnosing variant pancreatic ductal anatomy.
AB142 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
1109 Impact of EUS-FNA From Peritoneal Lesions for Avoiding Diagnostic Laparoscopy (Ipad Study): The First Prospective Study (Preliminary Results) Sirilak Yooprasert*1, Pradermchai Kongkam1, Wiriyaporn Ridtitid1, Piyapan Prueksapanich1, Sombat Treeprasertsuk1, Pinit Kullavanijaya1, Duangpen Thirabanjasak2, Rungsun Rerknimitr1 1 Internal medicine, Division of gastroenterology King chulalongkorn memorial hospital, Bangkok, Bangkok, Thailand; 2Pathology, Chulalongkorn University, Bangkok, Bangkok, Thailand Introduction: In patients with undiagnosed peritoneal diseases, diagnostic laparoscopy is often required to achieve a diagnosis but it is an invasive method to obtain tissue. For less invasive modality, endoscopic ultrasonography guided fine needle aspiration(EUS-FNA) is feasible for tissue acquisition. It is interesting to know efficacy of EUS-FNA for avoiding diagnostic laparoscopy in a prospective fashion. Aim: To study the efficacy of EUS-FNA for avoiding diagnostic laparoscopy in patients with peritoneal lesions. Methods: From December 2015 to October 2016, all consecutive patients with peritoneal lesions identified by CT at King Chulalongkorn Memorial Hospital, Bangkok, Thailand were enrolled into the study. Exclusion criteria were uncorrectable coagulopathy, pregnancy and age less than 18 years-old. EUS-FNA of peritoneal lesions was performed in all patients. Diagnostic laparoscopy was planned if pathological result of EUS-FNA was negative. Avoidance rate for diagnostic laparoscopy as a consequence of EUS-FNA was calculated. Results: Eighteen patients (9M; mean age+/- SD 60.9+/-14.7 years) were enrolled into the IPAD study. Presenting symptoms were weight loss (nZ18; 100%), jaundice (nZ8; 66.7%), abdominal distension (nZ5; 41.7%) and abdominal pain (nZ7; 38.9%). CT findings were soft tissue nodules/mass deposit in peritoneum (nZ13; 72.2%), ascites (nZ12; 66.7%), omental cake appearance (nZ6; 33.3%) and stranding of mesentery (nZ3; 16.7%). Final diagnoses were shown in table 1. Two benign cases were pancreatic ascites confirmed by laparoscopy and peritoneal tuberculosis confirmed by successful treatment. EUS-FNA showed positive results of malignancy in 14/18 patients (77.8%) and 28/54 passes (51.8%). Of 28 passes with positive results, 22/28 (78.6%) and 6/28 (21.4%) were obtained from hypoechoic peritoneal lesions and hyperechoic omental cake lesions, respectively. Interestingly, in 2 patients with benign peritoneal diseases, EUS revealed only thickening hyperechoic omental cake without hypoechoic peritoneal nodules. No adverse events were observed. Of 4 patients with negative results of EUS-FNA, 2 patients underwent diagnostic laparoscopy showing multiple omental and peritoneal nodules from metastatic gastric cancer (nZ1) and pancreatic ascites (nZ1); another 2 patients refused laparoscopy; one had advanced staged pancreatic cancer with poor performance status and another was clinically diagnosed as peritoneal tuberculosis with successful treatment. The sensitivity and specificity of EUS-FNA from peritoneal lesions were 87.5% and 100%, respectively. Based on results of EUS-FNA, diagnostic laparoscopy can be avoided in 14/18 (77.8%) patients (Table 2). Conclusions: In this prospective study,
www.giejournal.org
Abstracts
EUS-FNA has a high sensitivity rate for diagnosing causes peritoneal lesions and can avoid diagnostic laparoscopy in majority of patients.
Table 1: Demographic data of patients underwent EUS-FNA from peritoneal lesions EUS-FNA (n[18)
Data Male (n (%)) Age (year S.D.) Presenting symptoms
CT scan findings
EUS findings of peritoneal lesions
Final diagnosis
Weight loss jaundice Abdominal distension Abdominal pain Soft tissue nodules/mass deposit in peritoneum Ascites Omental cake appearance Stranding of mesentery Ascites Hypoechoic nodules deposit in peritoneum or omentum Thickening hyperechoic omental cake Pancreatic cancer Gallbladder Primary peritoneal carcinoma Gynecological cancer Bile duct cancer Colorectal cancer Gastric cancer Benign disease
9/18 (50%) 60.914.7 18/18 (100%) 10/18 (55.6%) 9/18 (50%) 7/18 (38.9%) 13/18 (72.2%) 12/18 (66.7%) 6/18 (33.3%) 3/18 (16.7%) 12/18 (66.7%) 11/18 (61.1%) 10/18 (55.6%) 6/18 (33.3%) 3/18 (16.7%) 2/18 (11.5%) 2/18 (11.1%) 1/18 (5.6%) 1/18 (5.6%) 1/18 (5.6%) 2/18 (11.1%)
procedures) and infection (12 studies; 10 events in 439 procedures) were 7.1%[95% CI (4.2 - 11.8)], 2.3%[95% CI (1.2 - 4.4)], 2.2%[95% CI (1.1 - 4.3)], 2%[95% CI (1.0 3.9)], 3.6%[95% CI (2.1 - 5.9)] respectively. In the studies that specifically reported clinical success with EUS-PDD as an outcome (10 studies; 265 events in 356 procedures), the clinical success rate was 70.3%[95% CI (54.9 - 82.2)]. There was substantial heterogeneity in the analysis of technical success rate and overall adverse events rate, which can be explained by subgroup analysis based on study location (Table 1). The technical success rate of EUS-PDD in the 4 studies that had an exclusive study population of post –Whipple surgery patients was 81.5%[95% CI (65.1 - 91.2)]. Conclusions: With a pooled technical success rate of 77%, EUS-PDD appears to be a promising alternative approach for PD decompression in patients who failed conventional ERCP. Among the EUS-PDD related adverse events, pancreatitis (7%) appears to be the most common. The high rate of overall adverse events highlights the importance of referring these procedures to high volume centers with more experience.
Subgroup analysis of success and post procedural complication rates Subgroups TECHNICAL SUCCESS Manuscript
No of studies
Rate (95% CI)
Subgroups
No of studies
Rate (95% CI)
13 9
77.7% (69.3 - 84.4) 75.9% (64.5 - 84.5)
BLEEDING Manuscript
12 9
2.3% (1.2 - 4.4) 2.8% (1.3 - 6.0)
Abstract
4
81.3% (66.3 - 90.6)
Abstract
3
1.2% (0.3 - 4.6)
North America
4
70.0% (57.0 - 80.5)
North America
4
1.8% (0.4 - 6.9)
Europe
4
73.6% (59.5 - 84.1)
Europe
4
4.0% (1.4 - 10.9)
Asia
2
72.1% (46.8 - 88.4)
Asia
1
2.8% (0.2 - 32.2)
Others
3
89.7% (81.9 - 94.3)
Others
3
1.2% (0.4 - 4.2)
CLINICAL SUCCESS
10
70.3% (54.9 - 82.2)
PERFORATION
12
2.2% (1.1 - 4.3)
Manuscript
7
60.4% (44.5 - 74.4)
Manuscript
9
2.7% (1.2 - 5.7)
Abstract
3
88.2% (73.0 - 95.4)
Abstract
3
1.2% (0.3 - 4.6)
North America
2
44.1% (23.5 - 67.0)
North America
4
1.8% (0.4 - 6.9)
Europe
3
54.0% (35.9 - 71.0)
Europe
4
3.2% (0.9 - 10.4)
Asia
2
85.4% (62.6 - 95.3)
Asia
1
2.8% (0.2 - 32.2)
Others
3
86.9% (76.8 - 93.0)
Others
3
1.8% (0.6 - 5.1)
ALL ADVERSE EVENTS
12
19.3% (13.3 - 27.0)
PANCREATIC LEAK
12
2.0% (1.0 - 3.9)
Manuscript
9
15.4% (9.2 - 24.6)
Manuscript
9
2.3% (1.0 - 5.1)
Abstract
3
26.4% (14.2 - 43.8)
Abstract
3
1.2% (0.3 - 4.6)
North America
4
13.5% (7.1 - 24.2)
North America
4
1.8% (0.4 - 6.9)
Europe
4
17.0% (8.7 - 30.4)
Europe
4
2.2% (0.5 - 8.3)
Asia
1
5.9% (7 - 35.8)
Asia
1
2.8% (0.2 - 32.2)
Others
3
30.2% (19.6 - 43.5)
Others
3
1.8% (0.6 - 5.1)
PANCREATITIS
12
7.1% (4.2 - 11.8)
INFECTION
12
3.6% (2.1 - 5.9)
Manuscript
9
5.6% (2.8 -10.9)
Manuscript
9
3.4% (1.7 - 6.5)
Abstract
3
10.1% (4.4 - 21.4)
Abstract
3
3.8% (1.7 - 8.5)
North America
4
13.6% (7.7 - 22.9)
North America
4
2.1% (0.6 - 7.2)
Europe
4
2.6% (0.8 - 8.9)
Europe
4
2.2% (0.5 - 8.3)
Asia
1
2.8% (0.2 - 32.9)
Asia
1
2.8% (0.2 - 32.2)
Others
3
7.6% (4.2 - 13.3)
Others
3
4.7% (2.4 - 8.7)
Table 2: Diagnostic yield of EUS-FNA from peritoneal lesions Parameters Sensitivity Specificity PPV NPV Accuracy Avoidance rate for diagnostic laparoscopy
Value 87.5% 100% 100% 50% 88.9% 77.8%
1110 Efficacy and Safety of Endoscopic Ultrasound (EUS) Guided Pancreatic Duct Drainage - A Systematic Review and Meta- Analysis Rajesh Krishnamoorthi*1, Mahendran Jayaraj2, Babu Pappu Mohan3, Varun K. Thiagarajan1, Michael C. Larsen1, Andrew S. Ross1, Shayan S. Irani1, Seng-Ian Gan1 1 Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA; 2 University of Nevada School of Medicine, Las Vegas, NV; 3University of Alabama, Tuscaloosa, AL Background: Endoscopic ultrasound (EUS) guided drainage of the pancreatic duct (PD) is a minimally invasive alternative to surgery for decompression of PD in patients who have failed conventional endoscopic retrograde cholangiopancreatography (ERCP) and in patients with altered anatomy. With improvement in EUS technology and specialized training programs in EUS procedures, the practice of EUS guided PD drainage (EUS-PDD) is expected to increase in future. However, there is significant variation in the reported rates of technical success and adverse events associated with EUS-PDD. We performed a systematic review and metaanalysis to estimate the success rate and adverse events (pancreatitis, bleeding, perforation, PD leak and infection). Methods: A comprehensive search of multiple electronic databases and conference proceedings (from inception through October 2016) was performed to identify studies reporting success rates and adverse events associated with EUS-PDD. The primary outcome was to estimate the pooled rate of technical success of EUS-PDD. The secondary outcome was to estimate the rate of EUS-PDD related adverse events. Results: The pooled rate of technical success of EUS-PDD (13 studies reporting a total of 450 procedures) was 77.7% [95% CI (69.3 84.4)] [Forest plot- Figure 1]. The pooled rate of overall adverse events related to EUS-PDD (12 studies; 91 events in 439 procedures) was 19.3% [95% CI (13.3 - 27)]. The pooled rate of individual adverse events - pancreatitis (12 studies; 28 events in 439 procedures), bleeding (12 studies; 5 events in 439 procedures), perforation (12 studies; 4 events in 439 procedures), PD leak (12 studies; 3 events in 439
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Figure 1: Forest plot: Technical success of EUS guided pancreatic duct drainage
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB143