Interventional EUS-Guided Cholangiography (IEUC): Long Term Experience of An Emerging Alternative to Percutaneous Transhepatic Cholangiography (PTC)

Abstracts

geometry was achieved. Conclusion: EUS guided FDS placement is feasible, safe and effective. Clinical experience shows that ideal geometry enables a larger proportion of inserted FDS to be tracked, thus improving the accuracy of treatment.

M1488 ‘‘A Prospective Randomized Trial of 1 Versus 2 Injections During a Single EUS-Guided Celiac Plexus Block (CPB) Procedure for Chronic Pancreatitis Pain: Final Results’’ Julia Leblanc, John Dewitt, Cindy Calley, Michelle Symms, Kathleen A. Mcgreevy, Lee Mchenry, Mohammad A. Al-Haddad, Stuart Sherman, Pradermchai Kongkam, Thomas F. Imperiale

M1487 Initial Experience with Endoscopic Ultrasound Guided Tru-Cut Biopsy for Known Or Suspected Benign Liver Disease John Dewitt, Kathleen A. Mcgreevy, Oscar Cummings, Stuart Sherman, Julia Leblanc, Lee Mchenry, Mohammad A. Al-Haddad, Naga P. Chalasani

Introduction: The relative efficacy of a single versus dual injection method during a single endoscopic ultrasound-guided celiac plexus block (EUS-CPB) procedure in patients with chronic pancreatitis is not known. Aim: To compare the clinical effectiveness and safety of EUS-CPB using a single injection at the celiac trunk takeoff from the aorta versus two injections (same total dosage) of steroid and bupivacaine into either side of the celiac axis in a single procedure in patients with pain due to chronic pancreatitis. The secondary aim is to identify factors that predict responsiveness to EUS-CPB. Methods: Consecutive subjects blinded to treatment group were randomized to receive a total dose of 20 ml 0.75% bupivacaine and 80 mg of triamcinolone by one injection into the takeoff of the celiac trunk or two injections on either side of the celiac axis during a single EUS-CPB procedure. Pre-procedure pain was assessed on a 10 point Likert scale. Patient characteristics were recorded. Follow up phone calls were made by a non-blinded nurse to assess for complications, pain relief, and use of pain medications at 24 hours and weekly thereafter until the subject no longer had pain relief. Response to EUS-CPB was defined as a subjective report of pain relief (yes/no) and any decrease in pain scores. Results: 51 subjects (31 women: median age 43 years; range 20 to 75) were randomized to receive one injection (n Z 23) or two injections (n Z 28). There were no complications. Pain relief was observed in 28 (55%) subjects with a mean (median) duration of 51.3 (28) days. The range of pain relief was 1-203 days. The Kaplan-Meier estimate of the median time to achieve pain relief in the one and two injection groups were 21 and 14 days respectively (p Z 1.0). Severity of chronic pancreatitis assessed by EUS, and prior EUS-CPB did not influence the response rate. Among subjects who had any pain relief, there was no correlation between duration of pain relief and time to onset of pain relief (Spearman’s rho Z -.02, p Z 0.9) There was no association between age, gender, race, prior EUS-CPB, smoking or alcohol history and either duration of, or time until pain relief. Conclusions: There is no difference in duration or onset of pain relief in patients with chronic pancreatitis and pain when one or two injections are used during EUS-CPB. Both one and two injections were safe EUS-CPB techniques. Age, severity of chronic pancreatitis, etiology, and duration of chronic pancreatitis did not predict response to EUS-CPB.

Background: Histologic liver biopsy is traditionally obtained by either a surgical, transvascular or percutaneous route. The utility of both EUS-FNA of the liver and EUS-guided Tru-Cut Biopsy (EUS-TCB) for extra-hepatic indications are established but the use EUS-TCB for known or suspected benign liver disease has not been described. Aim: To report our initial experience with EUS-TCB for known or suspected benign liver disease. Methods: Prospectively, outpatients with or without known chronic liver disease referred for routine upper EUS at our hospital were assessed for any potential benefit from simultaneous TCB of the liver. Eligible patients were examined by a staff hepatologist prior to EUS to corroborate the benefit of a biopsy. Exclusion criteria: planned future liver biopsy; known, suspected or discovered malignancy during EUS; esophageal or gastric varices; previous liver or upper GI tract surgery; platelets !150,000, hemoglobin !10 gm/dL; INRO1.2 or aPTT O 35 secs; use of anticoagulants or NSAIDs within 7 days; or required EUS-FNA of a liver lesion. Transgastric EUSTCB with a 19-gauge needle (Quick-Core; Cook Medical, Inc.; Winston-Salem, NC) into the left or caudate lobe was performed in all patients by one endosonographer. A maximum of 4 passes were made and no further biopsies were performed if the suspected length of all biopsies were R15 mm. Patients were monitored for R90 minutes prior to discharge and phoned within 24 hrs and at 30 days to assess for complications. Specimens were stained with reticulin and trichome and reviewed by a single pathologist for the number of portal spaces, to length, number of fragments, and final diagnosis. An adequate specimen was defined as at least 8 complete portal tracts. Results: 12 consecutive patients (mean: 44 yrs; 4 M) were enrolled. The indications for EUS-TCB, biopsy sites, tissue yield and diagnoses are shown in the Table. In 10 (83%) a diagnosis was obtained and in 2 (17%) it was nondiagnostic. There were no complications. Conclusion: EUS-TCB of suspected benign liver disease appears safe and feasible but usually provides a suboptimal sample than required for histologic assessment. Further evaluation with technique modifications is warranted.

M1489 Interventional EUS-Guided Cholangiography (IEUC): Long Term Experience of An Emerging Alternative to Percutaneous Transhepatic Cholangiography (PTC) Jennifer L. Maranki, Vanessa M. Shami, Alfredo J. Hernandez, Michel Kahaleh

Indications and Results of EUS-TCB of the Liver Median total Median Median length Indications EUSnumber of of all for EUSTCB fragments biopsies TCB passes Lobe(s) on slides (mm; (n Z 12) (range) biopsied (range) range) Suspected 3 (1-4) left 2 (1-7) 8 (1-13) NASH (n Z 5) (n Z 4); left and caudate (n Z 1)

Median length of largest fragment (mm; range) 4 (1-9)

Median number of partial portal tracts (n; range) 0 (0-5)

Median number of complete portal tracts (n; range) 3 (0-9)

Suspected cirrhosis (n Z 3)

3 (2-3)

left (n Z 3)

5 (4-6)

7 (6-9)

4 (3-5)

3 (2-4)

1 (0-2)

Suspected passive congestion (n Z 1) Intrahepatic cholestasis (n Z 1) Suspected FNH (n Z 1) NASH on Methotrexate (n Z 1) Total (n Z 12)

3

left

1

14

14

2

8

3

left

6

10

4

1

4

2

left

8

6

2

4

1

4

left & caudate

4

8

4

2

4

3 (1-4)

Left 4 (1-8) (n Z 10); Left & caudate (n Z 2)

8 (1-14)

4 (1-14)

2 (2-5)

2.5 (0-9)

Final diagnoses from EUS- TCB (n) NASH (n Z 1); steatosis (n Z 1); normal liver (n Z 1); nondiagnostic (n Z 2) bridging fibrosis (n Z 1); NASH (n Z 1); triaditis/ periportal fibrosis (n Z 1) normal liver

PSC vs druginduced hepatitis normal liver

steatosis and triaditis, no NASH

AB224 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008

Background: ERCP with stenting is the procedure of choice for biliary decompression in patients with obstructive jaundice. In cases where biliary access cannot be achieved, IEUC has become an alternative to PTC for biliary decompression. Objective: We report our five years experience in patients who underwent IEUC after failed ERCP. Methods: EUS-guided access to the targeted biliary duct was attempted with one of two approaches: transgastric-transhepatic (intrahepatic) or transenteric-transcholedochal (extrahepatic) with rendezvous. Once biliary access was confirmed by injection of contrast, a guide wire was then advanced through the EUS needle in an antegrade fashion. A stent was then advanced over the wire and into the biliary tree for decompression. In cases where the ampulla was not traversed, transenteric stents were deployed to achieve decompression. Results: 47 patients (26 male, 21 female) with mean age 60  17 years (range 3-90) underwent IEUC. 34 patients had biliary obstruction due to malignancy, while 13 had a benign etiology (see table). 38 patients underwent the intrahepatic approach, with conversion to the extrahepatic approach in 5 patients. Of the 33 patients who underwent the intrahepatic approach, 23 had a stent placed across the major papilla and 3 patients underwent placement of a gastrohepatic stent. Resolution of obstruction was achieved in 27 of 33 patients, with a success rate of 82%. In 6 patients, successful decompression was not achieved secondary to failure to advance the wire (5) or creation of a false channel (1). Complications occurred in 5 patients, including bleeding (1), pneumoperitoneum (3), and aspiration pneumonia (1). 14 patients underwent an extrahepatic approach (5 of whom were converted from the intrahepatic approach). In 8/14 (57%), stent placement across the major papilla was achieved. A transenteric stent was placed in 4 patients. Biliary decompression was achieved in 12/14 cases (86%). Complications occurred in 3/14 patients (21%), including biliary peritonitis, abdominal pain, and pneumoperitoneum. The overall success rate of IEUC was 81% (39/48), with an overall complication rate of 21%. There were no procedure related deaths. Conclusion: IEUC should be considered as an attractive alternative to PTC in patients presenting with obstructive jaundice after failed ERCP. The intrahepatic approach appears safer but seems to be more challenging than the extrahepatic approach.

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Abstracts

Comparison of Intra vs Extrahepatic approach ACCESS

ETIOLOGY

COMPLICATIONS

Intrahepatic

25 cancers, 4 surgical strictures, 4 benigns

Extrahepatic

9 cancers 5 benigns

1 1 1 1

bleeding, 3 pneumoperitoneum, aspiration pneumonia, biliary peritonitis, pneumoperitoneum, 1 pain

SUCCESS 27/33 12/14

M1490 Preoperative Detection of Familial Pancreatic Neoplasms By Endoscopic Ultrasonography (EUS), Multidetector Computed Tomography (CT), and/Or Magnetic Resonance Cholangiopancreatography (MRCP) Marcia I. Canto, Richard D. Schulick, Michael G. Goggins, Charles J. Yeo, John L. Cameron, Elliot K. Fishman, Ihab R. Kamel, Ralph H. Hruban Lives can be saved if high grade dysplasia (HGD) and early familial ductal adenocarcinoma (FPC) can be detected in high-risk individuals (HRI) before these lesions progress to advanced disease. AIM: 1) To characterize pancreatic neoplastic lesions detected by imaging tests in HRI. 2) To compare the diagnostic yield and incremental benefit of EUS over CT/MRCP for detection of pancreatic neoplasms in HRI. 3) To determine the incremental benefit of FNA over EUS alone. Methods: We analyzed data prospectively collected (1998-2007) from 2 screening studies and our clinical screening program. Adult HRI with Peutz-Jeghers syndrome (PJS) or firstdegree relatives from FPC kindreds with at least 2 affected had either multi-detector CT (1998-2004) and/or MRI/MRCP (2004-2007), and EUS. Radiologic and EUS features of each preoperatively detected lesion were compared with the pathologic findings. The diagnostic yield of each imaging modality was calculated on a per lesion basis. Results: Of 165 patients who had EUS and CT/MRCP, 19 asymptomatic HRI (16 FPC relatives, 2 PJS) underwent partial resection (15), partial followed by completion pancreatectomy (3), or total pancreatectomy (1) for 44 pancreatic lesions (size range 2.6-21 mm) detected by EUS, CT, and/or MRCP. There were 32 cysts: branch-duct intraductal papillary mucinous neoplasm (IPMN) (n Z 21), incipient IPMN (n Z 2), or large PanIN (n Z 4). 2 IPMNs with HGD were small (15 and 20 mm)with no mural nodules; the rest of the IPMNs had low or moderate grade dysplasia. EUS visualized 4 cysts that were ‘‘large’’ PanIN-3 (3-4 mm). There were 4 masses O 10 mm: invasive ductal CA (1), serous cystadenoma (1), chronic pancreatitis (1), and a pancreatic endocrine neoplasm (PEN). There were 8 nodules ! 10 mm: PEN (2), incipient IPMNs (2), and acinar nodules (4) associated with pancreatic intraepithelial neoplasia (PanIN). All 7 neoplasms with HGD/CA were 321 mm in size. CT, MRI/MRCP, and EUS detected 10/34 (29%), 13/26 (50%), and 43/ 44 (98%) of all lesions, respectively. MRCP was superior to CT for detection of cystic neoplasms (71% vs. 14%, p ! 001). The overall incremental benefit of EUS over MRCP and/or CT for detection of proven pancreatic neoplasia was 21/43 (49%) and was independent of lesion size - (12/31 (39%) for IPMNs or PanINs, 2/4 (50%) for masses, and 7/8 (88%) for nodules). EUS-FNA was suggestive of neoplasia in only 51% of lesions and did not change the EUS diagnosis in all cases. Conclusion: Most pancreatic neoplasms detected by screening tests are small and low-grade, but 6% of IPMNs ! 3 cm may contain HGD. EUS detects almost twice as many neoplastic lesions as CT/MRCP, regardless of size. FNA adds little to EUS.

M1491 Comparison of EUS-Guided One-Step Transmural Drainage of Pancreatic Pseudocysts and Conventional Transmural Drainage: A Prospective, Non-Blinded, Single Center, Randomized Study Sung-Hoon Moon, Sang Soo Lee, Do Hyun Park, Sun Young Choi, Ji Young Kim, Seok Won Jung, Dong Wan Seo, Sung Koo Lee, MyungHwan Kim Background/Aim. Endoscopic transmural drainage is a minimally invasive alternative to surgery or percutaneous drainage of pancreatic pseudocyst. Limitation of this technique is its relatively ‘‘blind’’ approach. Occasionally, bleeding or perforation is encountered during this procedure. Several investigators described the use of EUS for guidance of transmural puncture and performing drainage. However, there are few prospective comparative studies on EUS-guided versus conventional transmural drainage (CTD) of pseudocyst. The aim of the present study was to compare the outcome of EUS-guided drainage and CTD for pancreatic pseudocysts. Methods: This study was designed as a prospective, nonblinded, single center, randomized study. From January 2004 to November 2007, all patients were recruited, serially, as they presented for pancreatic pseudocyst that were treated by endoscopic transmural drainage. Results: A total of 54 patients underwent EUS-guided or CTD for pancreatic pseudocyst. 27 patients underwent EUS-guided drainage (group 1), and 27 patients underwent CTD (group 2). Two groups had similar demographic characteristics, etiologies, location and size of pseudocysts, presence of luminal bulging on endoscopy and indication for transmural drainage (Table 1). There were 3 cases of procedure-related bleeding and 1 case of perforation in group 2. While, stent migration to the cystic cavity occurred in group 1. There was no significant difference in complication rate for both groups (p O 0.05). Technical success rate of drainage was higher in group 1

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than group 2 (96.3% (26/27) vs. 66.7% (18/27), p ! 0.011). After successful drainage, pseudocyst resolution was achieved in 96.2% (25/26) of group 1 and 83.3% (15/18) of group 2. Conclusion: EUS-guided drainage of pancreatic pseudocysts may be technically more feasible than CTD. However, after successful drainage is achieved, the clinical outcome may be comparable in both methods.

Age (range) Gender (M:F) ) Size of Pseudocyst (mm, Mean  SD) Etiology Acute Chronic Postsurgery Location Head Body Tail Luminal bulging

Group 1 (EUS-guided, n Z 27)

Group 2 (Conventional, n Z 27)

47 (16-85) 22:5 8.5  4.0

49 (16-78) 20:7 7.4  4.2

13 11 3

12 13 2

5 8 14 13

8 11 8 17

p n-s n-s n-s n-s

n-s

n-s

)SD: standard deviation

M1492 EUS Guided Gold Fiducial Insertion for Image Guided Radiation Therapy of Pancreatic Cancer Brian M. Yan, Devin Schellenberg, Albert C. Koong, Jacques Van Dam Background and Aims: Image guided radiation therapy (IGRT) accurately delivers a high dose of radiation to a tumor while sparing adjacent organs and nonmalignant tissue. When treating patients with unresectable pancreatic cancer, gold fiducial markers (GF) have typically been inserted into the tumor percutaneously under computed tomography (CT) guidance. GF are used to track the precise location of the tumor, a necessary component of successful IGRT. In this study, we analyzed the feasibility of endoscopic insertion of GF under endoscopic ultrasound (EUS) guidance for the purpose of IGRT of pancreatic cancer. Methods: Patients with unresectable pancreatic adenocarcinoma underwent linear endosonography. GF were manually back-loaded into the tip of a 19 gauge needle (Wilson-Cook Medical, Winston-Salem, NC) and retained using lubricating jelly or bone wax. Under real time EUS guidance, the needle was placed inside the tumor and GF deployed by sterile water injection. GF placement was assessed one week later using radiation therapy planning CT scans. All patients with appropriate seed placement underwent IGRT. Results: A total of 23 patients were included. Eleven patients were male and 12 female. Mean age was 69 years old. Tumors were located in the head (15), neck (1), body (5), and uncinate (2). Mean diameter of the tumors was 4.63  1.71 cm. Mean volume of the tumors was 64.1  71.6 cm3. Technical success of GF delivery was achieved in 20 patients (87%). In one patient the needle’s stylet malfunctioned, in one patient the GF were lost, and one tumor was fibrotic and did not permit easy puncture by the 19 gauge needle. The three technical failures occurred early in the development of the technique. All subsequent patients underwent successful insertion of GF. Functional outcome, as defined by successful execution of IGRT, was assessable in 19 patients and successful in all. No early or delayed complications secondary to EUS guided GF insertion were observed. Conclusion: EUS-guided fine needle insertion is a safe and effective method for the delivery gold fiducial markers for image-guided radiation therapy.

M1493 Graded Dilation Technique for EUS-Guided Drainage of Peripancreatic Fluid Collections: An Assessment of Outcomes, Complications and Learning Curve Shyam Varadarajulu, Ashutosh Tamhane, Jeanetta Blakely Background: While the utility and safety of EUS/EUS-FNA is well known, more such data on EUS-guided drainage (EUS-D) procedures is needed due to the varied procedural techniques adopted and small numbers of patients in published series. Also, learning curve for performing EUS-D procedures is not known. Aim: Evaluate rates of technical and treatment success, complications and learning curve for performing EUS-D of peripancreatic fluid collections (PFC) in a large cohort of patients using the graded dilation technique. Methods: Prospective study of patients referred for EUS-D of PFC over 42-months. Patients with luminal compression underwent endoscopic transmural drainage and were excluded. All procedures were performed by one endosonographer. Technique: After passage of a guidewire into the PFC using a 19-gauge needle, graded dilation of the tract was sequentially performed using a 4.5 Fr ERCP cannula, 10Fr ERCP inner guiding catheter and 8 mm balloon dilator. Trans-mural stent/drainage catheter was then deployed. Electrocautery was not used in any patient. Technical success was defined as successful placement of stent/drain. Treatment success was defined as resolution of symptoms and PFC at 6 week follow-up. Complications were assessed at 24-hrs and day 30. Learning curve was evaluated by comparing the procedural duration between the first 25 cases (group A) and later cohort of patients (group B) undergoing EUS-D. Results: 60 patients underwent EUS-D of PFC (type: pseudocyst

Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB225