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Sa1453 Impact of Biliary Stents on EUS-Guided FNA
Abstracts
in 4 (PFC location: head/uncinate in 3 and body in 1) patients (frequency 1.3%, 95% CI [0.04%, 2.7%]), bleeding 7 (2.4%, 95% CI[0.64%, 4.12%]), infection 14 (4.7%, 95% CI [2.3%, 7.1%]) and stent migration in 3 (1.1%, 95% CI [0.1%, 2.2%]). There were six deaths from multi-organ dysfunction within 30 days of EUS of which none were procedure related. Conclusions: EUS-guided drainage of PFCs, in experienced hands, is associated with a low complication rate. This data can be used by endosonographers to counsel patients on the frequency of complications during EUS-guided drainage of PFCs.
Sa1451 EUS-Guided Therapy for Management of Pancreatic Fluid Collections (PFCs) After Distal Pancreatectomy (DP): A Definitive Solution to a Perennial Problem? Shyam Varadarajulu1, Mel Wilcox1, John D. Christein2 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2University of Alabama at Birmingham, Birmingham, AL Background: PFCs are a common complication occurring in up to 25-40% of patients after DP, be it either open or laparoscopic. Common treatment options include reoperation or percutaneous drainage. Surgery is associated with significant morbidity and percutaneous drainage is often times ineffective and predisposes to fistula formation. The role of EUS for management of PFCs in this context has been examined only in one small case series. Aim: To evaluate the role of EUS in the management of PFCs after DP in a large cohort of patients. Methods: In this prospective study, all patients with symptomatic PFCs (size ⬎ 4cm) after a DP underwent EUS-guided drainage. The procedures were undertaken as first line therapy or as rescue measure. The PFCs were accessed using a 19-gauge FNA needle and the transmural tract was sequentially dilated to 6mm (distal esophageal route) or 8mm (gastric route) followed by deployment of one (trans-esophagus) or two (trans-gastric) 7F double-pigtail stents. A followup CT was undertaken at 8-weeks to assess response to therapy and the stents were removed if the PFCs had resolved. The main outcome measures evaluated were treatment success and safety profile of the EUS-based approach. Treatment success was defined as resolution of symptoms and PFC at long-term follow-up. Results: Thirty four patients (20 females, mean age, 54.3 years [SD⫽13.2]) underwent EUS-guided drainage of PFCs after DP over a 6-yr period. EUS was undertaken as primary therapy in 22 patients (64.7%) and as rescue measure in 12 (35.3%) after failure of percutaneous drainage and/or transpapillary pancreatic stenting (n⫽11) and surgery (n⫽1). The mean size of the PFCs (largest dimension) was 76.6mm (SD⫽26.7). Given the location of the PFCs at the left upper quadrant, a definitive luminal compression was seen at endoscopy in only 1/34 (2.9%) patients. The PFCs were accessed via the transgastric route in 29 patients and transesophageal route in 5. Treatment was successful in 33 of 34 (97%) patients; 1 patient with persistent symptoms required reoperation. No complications were encountered. Three patients (8.8%) required a second intervention: 2 patients with persistent symptoms and residual PFC were treated with additional stents and one patient with an indwelling drainage catheter developed a percutaneous fistula that was managed by internal EUS-guided drainage. The transmural stents were retrieved at 8 weeks in 30 patients (91%) and left permanently in-situ in three patients (9%) who had main pancreatic duct strictures. At a mean follow-up of 304 days (SD⫽136.4), all 33 patients were doing well without symptom recurrence. Conclusions: EUS-guided drainage is a minimally invasive, safe, and highly effective technique that should be considered as a first-line treatment modality for the management of symptomatic PFCs after distal pancreatectomy.
Sa1452 Multiple Transluminal Gateway Technique for EUS-Guided Drainage of Walled Off Pancreatic Necrosis (WOPN) Shyam Varadarajulu1, Mel Wilcox1, John D. Christein2 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2General Surgery, University of Alabama at Birmingham, Birmingham, AL Background: Walled off pancreatic necrosis (WOPN) often times lead to severe clinical deterioration necessitating open debridement or endoscopic necrosectomy. A new EUS-based approach was devised to manage WOPN by creating multiple transluminal gateways to facilitate effective drainage of the necrotic contents. Aim: Compare treatment outcomes between patients with WOPN managed endoscopically by multiple transluminal gateway technique (MTGT) or conventional drainage techniques (CDT). Methods: Retrospective study of all patients with severe acute pancreatitis complicated by WOPN managed endoscopically at a tertiary referral center over a 6-yr period. In MTGT, two to three transmural tracts were created using EUS-guidance between the necrotic cavity and the GI lumen. While one tract was used to flush normal saline (120cc/4hrs) via a nasocystic catheter, multiple transmural stents (7/10Fr) were deployed in others to facilitate drainage of necrotic contents. In CDT, a nasocystic catheter and two stents were deployed through one transmural tract.
The main outcome measure was to compare the rate of treatment success between MTGT and CDT. Treatment success was defined as resolution of symptoms with improvement in radiological findings at follow-up CT and without the need for subsequent surgery or endoscopic necrosectomy. Results: Of 56 patients with WOPN, 12 (females 3, mean age 55.1 yrs) were managed by MTGT and 44 (females 12, mean age 55.2 yrs) by CDT. There was no difference in patient demographics or CT severity index between both cohorts. Treatment was successful in 11 of 12 (91.6%) patients managed by MTGT versus 24 of 44 (54.5%) managed by CDT (p⫽0.02). While one patient in the MTGT cohort required endoscopic necrosectomy, 14 patients in CDT cohort required surgery, 3 underwent endoscopic necrosectomy and 3 died of multi-organ failure. There was no difference in rate of procedural complications between the MTGT and CDT cohorts, 0 vs. 13.6%, p⫽0.32, respectively. At a median follow-up 189 days, all 11 patients treated successfully by the MTGT technique were doing well without symptom recurrence or need for surgery. Conclusions: The EUS-guided multiple transluminal gateway technique is an effective treatment option for the management of WOPN as it obviates the need for subsequent surgery, endoscopic necrosectomy and its attendant procedure-related morbidity. Prospective studies are required to confirm these preliminary but promising data.
Sa1453 Impact of Biliary Stents on EUS-Guided FNA Nathaniel R. Ranney, Mel Wilcox, Milind A. Phadnis, Shyam Varadarajulu Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL Background: There are no prior studies evaluating the impact of biliary stents on EUS-guided FNA. Aim: Compare the diagnostic yield of EUS-guided FNA in patients with or without biliary stents and presenting with obstructive jaundice secondary to solid pancreatic masses. Methods: Retrospective study of all patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-guided FNA over 5-yrs. Only patients in whom the pancreatic masses were sampled were included. Excluded were patients who underwent EUS-FNA of distant metastasis. The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic or metal biliary stents. The secondary objective was to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis between patients with or without stents and between plastic or metal stents. The gold standard was surgical cytopathology, death by disease progression or long-term follow-up. Results: 216 patients with obstructive jaundice secondary to solid pancreatic mass lesions underwent EUSguided FNA over a 5-yr period. Of 216 patients, 152 (70%) had biliary stents and 64 (30%) had no stents in place. Of 152 patients with biliary stents, 106 (70%) were plastic and 46 (30%) were metal. There was no difference in patient characteristics (Male, 49% vs. 50%, p⫽0.89; mean age 66.6 vs. 68.3 yrs, p⫽0.31) or size of the pancreatic mass on CT (2.9 vs. 3.0 cm; p⫽0.56) between patients with or without biliary stents, respectively. At EUS-guided FNA, the diagnosis was pancreatic cancer in 156 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%) and indeterminate in 12 (6%). There was no difference in rates of diagnostic accuracy for pancreatic cancer, chronic pancreatitis or other cancer between patients with or without stents (94.7% vs. 93.8 %; p⫽ 0.75) and between patients with plastic or metal stents (94.3% vs. 95.6%; p⫽0.99), respectively. The rates at which indeterminate diagnosis were encountered was not significantly different between patients with or without stents (5.3% vs. 6.3%; p⫽0.75) and between plastic or metal stents (5.7% vs. 4.4%; p⫽0.99), respectively. The total number of false negative FNA’s was 3 (1.4%) the rates of which was not significantly different between patients with or without biliary stents (1.97% vs. 0%; p⫽0.56) and between plastic or metal stents (1.9% vs. 2.2%; p⫽0.99), respectively. The median number of passes to establish diagnosis was not significantly different between patients with or without stents (2.5 vs. 2; p⫽0.051) and between plastic or metal stents (3 vs. 2; p⫽0.71), respectively. Conclusions: The presence or absence of a biliary stent, whether plastic or metal, does not impact the diagnostic yield or technical difficulty at EUS-guided FNA.
Sa1454 Quality Assessment of Current EUS-FNA Assembly Performance: Adequate for Use or Opportunity for Improvement? Shyam Varadarajulu1, Jeanetta Blakely1, Sahibzada U. Latif1, Mohamad A. Eloubeidi2 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2Medicine, American University at Beirut, Beirut, Lebanon Background: Although increasingly used, there are no data on the quality of current EUS-FNA needles. The objective of this study was to assess the quality of EUS-FNA needles used for diagnostic and therapeutic interventions. Methods: This study evaluated all EUS-FNA procedures performed between January-August 2010. The number of FNA needles used and the reasons for use of more than
AB174 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
in 4 (PFC location: head/uncinate in 3 and body in 1) patients (frequency 1.3%, 95% CI [0.04%, 2.7%]), bleeding 7 (2.4%, 95% CI[0.64%, 4.12%]), infection 14 (4.7%, 95% CI [2.3%, 7.1%]) and stent migration in 3 (1.1%, 95% CI [0.1%, 2.2%]). There were six deaths from multi-organ dysfunction within 30 days of EUS of which none were procedure related. Conclusions: EUS-guided drainage of PFCs, in experienced hands, is associated with a low complication rate. This data can be used by endosonographers to counsel patients on the frequency of complications during EUS-guided drainage of PFCs.
Sa1451 EUS-Guided Therapy for Management of Pancreatic Fluid Collections (PFCs) After Distal Pancreatectomy (DP): A Definitive Solution to a Perennial Problem? Shyam Varadarajulu1, Mel Wilcox1, John D. Christein2 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2University of Alabama at Birmingham, Birmingham, AL Background: PFCs are a common complication occurring in up to 25-40% of patients after DP, be it either open or laparoscopic. Common treatment options include reoperation or percutaneous drainage. Surgery is associated with significant morbidity and percutaneous drainage is often times ineffective and predisposes to fistula formation. The role of EUS for management of PFCs in this context has been examined only in one small case series. Aim: To evaluate the role of EUS in the management of PFCs after DP in a large cohort of patients. Methods: In this prospective study, all patients with symptomatic PFCs (size ⬎ 4cm) after a DP underwent EUS-guided drainage. The procedures were undertaken as first line therapy or as rescue measure. The PFCs were accessed using a 19-gauge FNA needle and the transmural tract was sequentially dilated to 6mm (distal esophageal route) or 8mm (gastric route) followed by deployment of one (trans-esophagus) or two (trans-gastric) 7F double-pigtail stents. A followup CT was undertaken at 8-weeks to assess response to therapy and the stents were removed if the PFCs had resolved. The main outcome measures evaluated were treatment success and safety profile of the EUS-based approach. Treatment success was defined as resolution of symptoms and PFC at long-term follow-up. Results: Thirty four patients (20 females, mean age, 54.3 years [SD⫽13.2]) underwent EUS-guided drainage of PFCs after DP over a 6-yr period. EUS was undertaken as primary therapy in 22 patients (64.7%) and as rescue measure in 12 (35.3%) after failure of percutaneous drainage and/or transpapillary pancreatic stenting (n⫽11) and surgery (n⫽1). The mean size of the PFCs (largest dimension) was 76.6mm (SD⫽26.7). Given the location of the PFCs at the left upper quadrant, a definitive luminal compression was seen at endoscopy in only 1/34 (2.9%) patients. The PFCs were accessed via the transgastric route in 29 patients and transesophageal route in 5. Treatment was successful in 33 of 34 (97%) patients; 1 patient with persistent symptoms required reoperation. No complications were encountered. Three patients (8.8%) required a second intervention: 2 patients with persistent symptoms and residual PFC were treated with additional stents and one patient with an indwelling drainage catheter developed a percutaneous fistula that was managed by internal EUS-guided drainage. The transmural stents were retrieved at 8 weeks in 30 patients (91%) and left permanently in-situ in three patients (9%) who had main pancreatic duct strictures. At a mean follow-up of 304 days (SD⫽136.4), all 33 patients were doing well without symptom recurrence. Conclusions: EUS-guided drainage is a minimally invasive, safe, and highly effective technique that should be considered as a first-line treatment modality for the management of symptomatic PFCs after distal pancreatectomy.
Sa1452 Multiple Transluminal Gateway Technique for EUS-Guided Drainage of Walled Off Pancreatic Necrosis (WOPN) Shyam Varadarajulu1, Mel Wilcox1, John D. Christein2 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2General Surgery, University of Alabama at Birmingham, Birmingham, AL Background: Walled off pancreatic necrosis (WOPN) often times lead to severe clinical deterioration necessitating open debridement or endoscopic necrosectomy. A new EUS-based approach was devised to manage WOPN by creating multiple transluminal gateways to facilitate effective drainage of the necrotic contents. Aim: Compare treatment outcomes between patients with WOPN managed endoscopically by multiple transluminal gateway technique (MTGT) or conventional drainage techniques (CDT). Methods: Retrospective study of all patients with severe acute pancreatitis complicated by WOPN managed endoscopically at a tertiary referral center over a 6-yr period. In MTGT, two to three transmural tracts were created using EUS-guidance between the necrotic cavity and the GI lumen. While one tract was used to flush normal saline (120cc/4hrs) via a nasocystic catheter, multiple transmural stents (7/10Fr) were deployed in others to facilitate drainage of necrotic contents. In CDT, a nasocystic catheter and two stents were deployed through one transmural tract.
The main outcome measure was to compare the rate of treatment success between MTGT and CDT. Treatment success was defined as resolution of symptoms with improvement in radiological findings at follow-up CT and without the need for subsequent surgery or endoscopic necrosectomy. Results: Of 56 patients with WOPN, 12 (females 3, mean age 55.1 yrs) were managed by MTGT and 44 (females 12, mean age 55.2 yrs) by CDT. There was no difference in patient demographics or CT severity index between both cohorts. Treatment was successful in 11 of 12 (91.6%) patients managed by MTGT versus 24 of 44 (54.5%) managed by CDT (p⫽0.02). While one patient in the MTGT cohort required endoscopic necrosectomy, 14 patients in CDT cohort required surgery, 3 underwent endoscopic necrosectomy and 3 died of multi-organ failure. There was no difference in rate of procedural complications between the MTGT and CDT cohorts, 0 vs. 13.6%, p⫽0.32, respectively. At a median follow-up 189 days, all 11 patients treated successfully by the MTGT technique were doing well without symptom recurrence or need for surgery. Conclusions: The EUS-guided multiple transluminal gateway technique is an effective treatment option for the management of WOPN as it obviates the need for subsequent surgery, endoscopic necrosectomy and its attendant procedure-related morbidity. Prospective studies are required to confirm these preliminary but promising data.
Sa1453 Impact of Biliary Stents on EUS-Guided FNA Nathaniel R. Ranney, Mel Wilcox, Milind A. Phadnis, Shyam Varadarajulu Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL Background: There are no prior studies evaluating the impact of biliary stents on EUS-guided FNA. Aim: Compare the diagnostic yield of EUS-guided FNA in patients with or without biliary stents and presenting with obstructive jaundice secondary to solid pancreatic masses. Methods: Retrospective study of all patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-guided FNA over 5-yrs. Only patients in whom the pancreatic masses were sampled were included. Excluded were patients who underwent EUS-FNA of distant metastasis. The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic or metal biliary stents. The secondary objective was to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis between patients with or without stents and between plastic or metal stents. The gold standard was surgical cytopathology, death by disease progression or long-term follow-up. Results: 216 patients with obstructive jaundice secondary to solid pancreatic mass lesions underwent EUSguided FNA over a 5-yr period. Of 216 patients, 152 (70%) had biliary stents and 64 (30%) had no stents in place. Of 152 patients with biliary stents, 106 (70%) were plastic and 46 (30%) were metal. There was no difference in patient characteristics (Male, 49% vs. 50%, p⫽0.89; mean age 66.6 vs. 68.3 yrs, p⫽0.31) or size of the pancreatic mass on CT (2.9 vs. 3.0 cm; p⫽0.56) between patients with or without biliary stents, respectively. At EUS-guided FNA, the diagnosis was pancreatic cancer in 156 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%) and indeterminate in 12 (6%). There was no difference in rates of diagnostic accuracy for pancreatic cancer, chronic pancreatitis or other cancer between patients with or without stents (94.7% vs. 93.8 %; p⫽ 0.75) and between patients with plastic or metal stents (94.3% vs. 95.6%; p⫽0.99), respectively. The rates at which indeterminate diagnosis were encountered was not significantly different between patients with or without stents (5.3% vs. 6.3%; p⫽0.75) and between plastic or metal stents (5.7% vs. 4.4%; p⫽0.99), respectively. The total number of false negative FNA’s was 3 (1.4%) the rates of which was not significantly different between patients with or without biliary stents (1.97% vs. 0%; p⫽0.56) and between plastic or metal stents (1.9% vs. 2.2%; p⫽0.99), respectively. The median number of passes to establish diagnosis was not significantly different between patients with or without stents (2.5 vs. 2; p⫽0.051) and between plastic or metal stents (3 vs. 2; p⫽0.71), respectively. Conclusions: The presence or absence of a biliary stent, whether plastic or metal, does not impact the diagnostic yield or technical difficulty at EUS-guided FNA.
Sa1454 Quality Assessment of Current EUS-FNA Assembly Performance: Adequate for Use or Opportunity for Improvement? Shyam Varadarajulu1, Jeanetta Blakely1, Sahibzada U. Latif1, Mohamad A. Eloubeidi2 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2Medicine, American University at Beirut, Beirut, Lebanon Background: Although increasingly used, there are no data on the quality of current EUS-FNA needles. The objective of this study was to assess the quality of EUS-FNA needles used for diagnostic and therapeutic interventions. Methods: This study evaluated all EUS-FNA procedures performed between January-August 2010. The number of FNA needles used and the reasons for use of more than
AB174 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org