- Email: [email protected]
Percutaneous Preoperative Biliary Drainage for Malignant Hilar Biliary Obstruction: E-Pod Hilar Study
Abstracts
Tu1450 A Retrospective Study of Endoscopic/Percutaneous Preoperative Biliary Drainage for Malignant Hilar Biliary Obstruction: E-Pod Hilar Study Masato Matsuyama*3, Yousuke Nakai1, Ryuichi Yamamoto2, Yuji Sakai4, Yukiko Takayama5, Kiichi Tamada6, Yukiko Ito7, Katsuya Kitamura8, Shomei Ryozawa9, Tsunao Imamura10, Kouhei Tsuchida11, Jo Hayama12, Takao Itoi13, Yoshiaki Kawaguchi14, Yu Yoshida15, Kazuya Sugimori16, Kenji Shimura17, Masafumi Mizuide18, Tomohisa Iwai19, Ko Nishikawa20, Hiroshi Yagioka21, Masatsugu Nagahama22, Nobuo Toda23, Tomotaka Saito24, Ichiro Yasuda25, Kenji Hirano26, Osamu Togawa27, Kenji Nakamura28, Iruru Maetani29, Hiroyuki Isayama1 1 The University of Tokyo, Tokyo, Japan; 2Saitama Medical Center, Saitma Medical University, Saitama, Japan; 3The Cancer Institute Hospital of JFCR, Tokyo, Japan; 4Chiba University Hospital, Chiba, Japan; 5Tokyo Women’s Medical University, Tokyo, Japan; 6Jichi Medical University Hospital, Tochigi, Japan; 7Japanese Redcross Medical Center, Tokyo, Japan; 8Showa University School of Medicine, Tokyo, Japan; 9Saitama Medical University International Medical Center, Saitama, Japan; 10Toranomon Hospital, Tokyo, Japan; 11Dokkyo Medical University, Tochigi, Japan; 12Nihon University Itabashi Hospital, Tokyo, Japan; 13Tokyo Medical University, Tokyo, Japan; 14Tokai University School of Medicine, Kanagawa, Japan; 15Kimitsu Chuo Hospital, Chiba, Japan; 16Yokohama City University Medical Center, Kanagawa, Japan; 17Asahi General Hospital, Chiba, Japan; 18Gunma University Hospital, Gunma, Japan; 19Kitasato University Hospital, Kanagawa, Japan; 20Ageo Central General Hospital, Saitama, Japan; 21 Tokyo Metropolitan Police Hospital, Tokyo, Japan; 22Showa University Fujigaoka Hospital, Kanagawa, Japan; 23Mitsui Memorial Hospital, Tokyo, Japan; 24JR Tokyo General Hospital, Tokyo, Japan; 25Teikyo University Mizonokuchi Hospital, Kanagawa, Japan; 26Tokyo Takanawa Hospital, Tokyo, Japan; 27Kanto Central Hospital, Tokyo, Japan; 28St.Luke’s International Hospital, Tokyo, Japan; 29Toho University Ohashi Medical Center, Tokyo, Japan Background: While Endoscopic nasobiliary drainage (ENBD) is often recommended in preoperative biliary drainage for hilar malignant biliary obstruction (MBO), endoscopic biliary stent (EBS) or PTBD is also performed in the clinical practice. Patients: Consecutive patients undergoing preoperative biliary derange for hilar MBO in 29 centers between Jan 2010 and May 2015 were retrospectively studied. Data on the type of drainage, adverse events, the rate of and time to resolution of jaundice, time to surgery, re-interventions and survival were analyzed. Results: A total of 374 patients met the inclusion criteria (Table 1). The initial drainage was ENBD/EBS/PTBD 75％/20%/3%. ERCP was technically successful in 94.6%. The major adverse events were post-ERCP pancreatitis (overall 15%, mild 12%, moderate 2% and severe 1%), and the only risk factor for PEP was non-EST (odds ratio [OR] 2.53, pZ0.01). The resolution of jaundice by the initial drainage alone was obtained in 77.8% within a median of 17 days. The risk factors for unsuccessful resolution of jaundice were total bilirubin (TB)10 mg/dL (OR 3.49, p<0.01), CRP<1.5 mg/dL (OR 2.00, p<0.01), male (OR 1.53, pZ0.01). Preoeprative re-intervention was performed in 61% (planned procedures for pathological diagnosis or stent exchange in 49% and unplanned procedures for cholangitis or tube dislocation in 31%). Surgical resection was performed in 90％ after a median of 36 days (35 days in ENBD and 41 days in EBS, pZ0.07). The reasons for unresectability were progressive disease in 6%, patient preference in 2%, and uncontrolled cholangitis/jaundice in 1%. The median survival was 4.3 and 1.1 years in resected and unresected cases, respectively. At the time of surgery, ENBD, EBS and PTBD were placed in 60%, 36% and 7%. The median number of and time to re-intervention in surgically resected cases was 2 and 15 days in ENBD group and 1 and 49 days in EBS group. The risk factors for unplanned procedures were extrahepatic bile duct cancer (OR 2.26, pZ0.01) and TB10(OR 2.48, p<0.01). In surgically resected extrahepatic bile duct cancer, poor prognostic factors were predrainage cholangitis (hazard ratio [HR] 2.12, pZ0.03), unplanned procedures (HR 1.91, pZ0.01), predrainage MRCP(HR 1.85, pZ0.01). Conclusion: Median time to surgery in hilar MBO was 36 days with re-intervention rate of 61%. There were no significant differences in clinical outcomes between ENBD and EBS.
Patient characteristics, drainage and outcomes
Age Sex PS
Primary disease
Male 0 1 2Extrahepatic cholangiocarcinoma Intrahepatic cholangiocarcinoma
www.giejournal.org
All (n [ 374)
ENBD (n [ 281)
EBS (n [ 76)
70 (65-76) 66% 66% 31% 3% 70%
71 (64-76) 67% 64% 32% 2% 68%
70 (65-74) 62% 63% 26% 3% 80%
18%
21%
11%
P-value 0.537 0.413 0.034
0.078
Gallbladder cancer 1 2 3a 3b 4
Bismuth
Drainage procedure Predrainage total bilirubin (mg/dL) Predrainage cholangitis Single drainage tube Technical success Resolution of jaundice Adverse events
Any Post-ERCP pancreatitis Cholangitis Dislocation
Total number of interventions Preoperative cholangitis PTBD at surgery Curative intent surgery Median survival time, yrs
All (n [ 374)
ENBD (n [ 281)
EBS (n [ 76)
11%
11%
8%
18% 11% 14% 14% 31%
14% 20% 13% 15% 36%
33% 26% 13% 11% 16%
0.001
4.1(1.1-11.0)
3.4 (1.1-16.2)
5.3 (1.4-12.4)
0.121
10% 87% 90% 78% 22% 16%
10% 93% 90% 76% 20% 14%
12% 66% 96% 88% 24% 20%
0.527 <0.001 0.724 0.074 0.528 0.210
3% 3% 2(1-3)
2% 4% 2(1-3)
4% 0 1(1-3)
0.436 0.130 0.084
17% 7% 90% 3.3
16% 6% 91% 3.3
24% 0 89% 2.7
0.129 0.029 0.823 0.834
P-value
Numbers are shown in % or median (IQR)
Tu1451 Sheath Rinsing: A Technique for Improved Cellular Yield in Biliary Brushing Cytology Subhash Chandra*1, Glenda Amog-Jones2, Chris Jensen1, Frederick C. Johlin1 1 University of Iowa, Coralville, IA; 2Pathology, Phoenix VA Health Care System, Phoenix, AZ Background: Biliary brushing cytology is a common diagnostic tool to evaluate pancreatic and biliary strictures. Although this technique has been shown to have a high specificity, it has a relatively low reported sensitivity. False negatives are usually attributed to scant cellularity and poor cellular preservation. In this pilot study, we sought to determine impact of sheath rinsing on cellular yield of biliary brush cytology for biliary stricture. Methods: Consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) over a one month period for biliary strictures were enrolled in the study. The specimens were obtained during the ERCP by brushing the common bile duct, common hepatic duct, and right and left hepatic ducts. The lead edge of the sheath and the brush were advanced and withdrawn through the stricture for a total of 15 in and out movements. Paired brush and sheath rinse were done on the same site and submitted separately. Thin-layer and cell block preparations were prepared. The cellularity assessment was blinded. Results: Moderate or high cellularity was noted in 8 out of 13 (62%) brush specimens and 10 out of 13 (77%) sheath rinsing specimens, Figure 1. Four of 13 (30.1%) specimens using sheath rinse showed better yield than brush specimens and none of brush specimens had better cellularity. The combination of the brush and sheath rinse showed moderate to high cellularity in 10 of 13 (77%) cases. Conclusions: In biliary brushing cytology, advancing brush and sheath through the stricture and sending sheath rinse for cytology increases the yield without needing additional instruments or significant operator efforts. Based on the simplicity and no additional cost, it has potential for widespread adoption.
Table 1. Assessment of cellularity between thin layer and cell block preparations of brushing and sheath rinsing Brushing Specimen 1 2 3 4 5 6 7 8 9 10 11 12 13
Thin layer 1 1 0 1 3 2 2 2 1 2 1 0 1
Cell block 2 2 2 1 2 1 1 1 0 1 NP NP 1
Sheath Overall 2 2 2 1 3 2 2 2 1 2 1 2 1
Thin layer 0 0 1 1 3 2 1 3 1 2 3 0 0
Cell block 2 2 2 2 2 2 NP 1 1 1 1 1 1
Overall 2 2 2 2 3 2 2 3 1 2 3 1 1
NP: Not prepared. 1) low (few single cells or small sheets), 2) moderate (few to many small clusters and few large sheets) and 3) high (many small clusters and large sheets).
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB633
Tu1450 A Retrospective Study of Endoscopic/Percutaneous Preoperative Biliary Drainage for Malignant Hilar Biliary Obstruction: E-Pod Hilar Study Masato Matsuyama*3, Yousuke Nakai1, Ryuichi Yamamoto2, Yuji Sakai4, Yukiko Takayama5, Kiichi Tamada6, Yukiko Ito7, Katsuya Kitamura8, Shomei Ryozawa9, Tsunao Imamura10, Kouhei Tsuchida11, Jo Hayama12, Takao Itoi13, Yoshiaki Kawaguchi14, Yu Yoshida15, Kazuya Sugimori16, Kenji Shimura17, Masafumi Mizuide18, Tomohisa Iwai19, Ko Nishikawa20, Hiroshi Yagioka21, Masatsugu Nagahama22, Nobuo Toda23, Tomotaka Saito24, Ichiro Yasuda25, Kenji Hirano26, Osamu Togawa27, Kenji Nakamura28, Iruru Maetani29, Hiroyuki Isayama1 1 The University of Tokyo, Tokyo, Japan; 2Saitama Medical Center, Saitma Medical University, Saitama, Japan; 3The Cancer Institute Hospital of JFCR, Tokyo, Japan; 4Chiba University Hospital, Chiba, Japan; 5Tokyo Women’s Medical University, Tokyo, Japan; 6Jichi Medical University Hospital, Tochigi, Japan; 7Japanese Redcross Medical Center, Tokyo, Japan; 8Showa University School of Medicine, Tokyo, Japan; 9Saitama Medical University International Medical Center, Saitama, Japan; 10Toranomon Hospital, Tokyo, Japan; 11Dokkyo Medical University, Tochigi, Japan; 12Nihon University Itabashi Hospital, Tokyo, Japan; 13Tokyo Medical University, Tokyo, Japan; 14Tokai University School of Medicine, Kanagawa, Japan; 15Kimitsu Chuo Hospital, Chiba, Japan; 16Yokohama City University Medical Center, Kanagawa, Japan; 17Asahi General Hospital, Chiba, Japan; 18Gunma University Hospital, Gunma, Japan; 19Kitasato University Hospital, Kanagawa, Japan; 20Ageo Central General Hospital, Saitama, Japan; 21 Tokyo Metropolitan Police Hospital, Tokyo, Japan; 22Showa University Fujigaoka Hospital, Kanagawa, Japan; 23Mitsui Memorial Hospital, Tokyo, Japan; 24JR Tokyo General Hospital, Tokyo, Japan; 25Teikyo University Mizonokuchi Hospital, Kanagawa, Japan; 26Tokyo Takanawa Hospital, Tokyo, Japan; 27Kanto Central Hospital, Tokyo, Japan; 28St.Luke’s International Hospital, Tokyo, Japan; 29Toho University Ohashi Medical Center, Tokyo, Japan Background: While Endoscopic nasobiliary drainage (ENBD) is often recommended in preoperative biliary drainage for hilar malignant biliary obstruction (MBO), endoscopic biliary stent (EBS) or PTBD is also performed in the clinical practice. Patients: Consecutive patients undergoing preoperative biliary derange for hilar MBO in 29 centers between Jan 2010 and May 2015 were retrospectively studied. Data on the type of drainage, adverse events, the rate of and time to resolution of jaundice, time to surgery, re-interventions and survival were analyzed. Results: A total of 374 patients met the inclusion criteria (Table 1). The initial drainage was ENBD/EBS/PTBD 75％/20%/3%. ERCP was technically successful in 94.6%. The major adverse events were post-ERCP pancreatitis (overall 15%, mild 12%, moderate 2% and severe 1%), and the only risk factor for PEP was non-EST (odds ratio [OR] 2.53, pZ0.01). The resolution of jaundice by the initial drainage alone was obtained in 77.8% within a median of 17 days. The risk factors for unsuccessful resolution of jaundice were total bilirubin (TB)10 mg/dL (OR 3.49, p<0.01), CRP<1.5 mg/dL (OR 2.00, p<0.01), male (OR 1.53, pZ0.01). Preoeprative re-intervention was performed in 61% (planned procedures for pathological diagnosis or stent exchange in 49% and unplanned procedures for cholangitis or tube dislocation in 31%). Surgical resection was performed in 90％ after a median of 36 days (35 days in ENBD and 41 days in EBS, pZ0.07). The reasons for unresectability were progressive disease in 6%, patient preference in 2%, and uncontrolled cholangitis/jaundice in 1%. The median survival was 4.3 and 1.1 years in resected and unresected cases, respectively. At the time of surgery, ENBD, EBS and PTBD were placed in 60%, 36% and 7%. The median number of and time to re-intervention in surgically resected cases was 2 and 15 days in ENBD group and 1 and 49 days in EBS group. The risk factors for unplanned procedures were extrahepatic bile duct cancer (OR 2.26, pZ0.01) and TB10(OR 2.48, p<0.01). In surgically resected extrahepatic bile duct cancer, poor prognostic factors were predrainage cholangitis (hazard ratio [HR] 2.12, pZ0.03), unplanned procedures (HR 1.91, pZ0.01), predrainage MRCP(HR 1.85, pZ0.01). Conclusion: Median time to surgery in hilar MBO was 36 days with re-intervention rate of 61%. There were no significant differences in clinical outcomes between ENBD and EBS.
Patient characteristics, drainage and outcomes
Age Sex PS
Primary disease
Male 0 1 2Extrahepatic cholangiocarcinoma Intrahepatic cholangiocarcinoma
www.giejournal.org
All (n [ 374)
ENBD (n [ 281)
EBS (n [ 76)
70 (65-76) 66% 66% 31% 3% 70%
71 (64-76) 67% 64% 32% 2% 68%
70 (65-74) 62% 63% 26% 3% 80%
18%
21%
11%
P-value 0.537 0.413 0.034
0.078
Gallbladder cancer 1 2 3a 3b 4
Bismuth
Drainage procedure Predrainage total bilirubin (mg/dL) Predrainage cholangitis Single drainage tube Technical success Resolution of jaundice Adverse events
Any Post-ERCP pancreatitis Cholangitis Dislocation
Total number of interventions Preoperative cholangitis PTBD at surgery Curative intent surgery Median survival time, yrs
All (n [ 374)
ENBD (n [ 281)
EBS (n [ 76)
11%
11%
8%
18% 11% 14% 14% 31%
14% 20% 13% 15% 36%
33% 26% 13% 11% 16%
0.001
4.1(1.1-11.0)
3.4 (1.1-16.2)
5.3 (1.4-12.4)
0.121
10% 87% 90% 78% 22% 16%
10% 93% 90% 76% 20% 14%
12% 66% 96% 88% 24% 20%
0.527 <0.001 0.724 0.074 0.528 0.210
3% 3% 2(1-3)
2% 4% 2(1-3)
4% 0 1(1-3)
0.436 0.130 0.084
17% 7% 90% 3.3
16% 6% 91% 3.3
24% 0 89% 2.7
0.129 0.029 0.823 0.834
P-value
Numbers are shown in % or median (IQR)
Tu1451 Sheath Rinsing: A Technique for Improved Cellular Yield in Biliary Brushing Cytology Subhash Chandra*1, Glenda Amog-Jones2, Chris Jensen1, Frederick C. Johlin1 1 University of Iowa, Coralville, IA; 2Pathology, Phoenix VA Health Care System, Phoenix, AZ Background: Biliary brushing cytology is a common diagnostic tool to evaluate pancreatic and biliary strictures. Although this technique has been shown to have a high specificity, it has a relatively low reported sensitivity. False negatives are usually attributed to scant cellularity and poor cellular preservation. In this pilot study, we sought to determine impact of sheath rinsing on cellular yield of biliary brush cytology for biliary stricture. Methods: Consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) over a one month period for biliary strictures were enrolled in the study. The specimens were obtained during the ERCP by brushing the common bile duct, common hepatic duct, and right and left hepatic ducts. The lead edge of the sheath and the brush were advanced and withdrawn through the stricture for a total of 15 in and out movements. Paired brush and sheath rinse were done on the same site and submitted separately. Thin-layer and cell block preparations were prepared. The cellularity assessment was blinded. Results: Moderate or high cellularity was noted in 8 out of 13 (62%) brush specimens and 10 out of 13 (77%) sheath rinsing specimens, Figure 1. Four of 13 (30.1%) specimens using sheath rinse showed better yield than brush specimens and none of brush specimens had better cellularity. The combination of the brush and sheath rinse showed moderate to high cellularity in 10 of 13 (77%) cases. Conclusions: In biliary brushing cytology, advancing brush and sheath through the stricture and sending sheath rinse for cytology increases the yield without needing additional instruments or significant operator efforts. Based on the simplicity and no additional cost, it has potential for widespread adoption.
Table 1. Assessment of cellularity between thin layer and cell block preparations of brushing and sheath rinsing Brushing Specimen 1 2 3 4 5 6 7 8 9 10 11 12 13
Thin layer 1 1 0 1 3 2 2 2 1 2 1 0 1
Cell block 2 2 2 1 2 1 1 1 0 1 NP NP 1
Sheath Overall 2 2 2 1 3 2 2 2 1 2 1 2 1
Thin layer 0 0 1 1 3 2 1 3 1 2 3 0 0
Cell block 2 2 2 2 2 2 NP 1 1 1 1 1 1
Overall 2 2 2 2 3 2 2 3 1 2 3 1 1
NP: Not prepared. 1) low (few single cells or small sheets), 2) moderate (few to many small clusters and few large sheets) and 3) high (many small clusters and large sheets).
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB633