Tu1616 Biliary Fully Covered Self-Expandable Metal Stents - a New Alternative for Proximal Esophageal Stricture and Fistula Treatment?

Image 1. Left image revealing large esophageal perforation. Right image demonstrating successful deployment of self expanding plastic stent over esophageal tear. Image 2. Intraoperative fluoroscopic evaluation during guidewire placement prior to stent deployment. Tu1616 Biliary Fully Covered Self-Expandable Metal Stents a New Alternative for Proximal Esophageal Stricture and Fistula Treatment? Donnesha Clayton*, Michael J. Bartel, Timothy A. Woodward Internal Medicine, Mayo Clinic, Jacksonville, FL; Gastroenterology, Mayo Clinic, Jacksonville, FL Background & Aim: Proximal complex benign esophageal strictures represent a subset of esophageal strictures which are particularly challenging to treat. In this context, placement of conventional esophageal stents is often limited by significant globus sensation.We report the use of biliary stents for endoscopic treatment of proximal esophageal strictures and fistulas. Methods: Prospectively collected data was abstracted by retrospective chart review of all patients who underwent biliary stent placement for complex benign esophageal strictures or fistula between 2011 and 2014. All patients underwent upper endoscopy followed by stent placement.The primary endpoint was to demonstrate an improvement of dysphagia in case of stricture or healing of fistula. Secondary endpoint was to determine complications. Results: 5 patients (mean age 61 years, SD 16; 80% male) with 3 radiation-induced strictures of which 1 had also an anastomotic fistula, 1 anastomotic stricture and 1 anastomotic fistula without stricture were included. Esophageal strictures had a mean length of 23mm (SD 11.5), and a mean diameter of 6mm (SD 2.5). Strictures and the fistula were located 15 to 23cm from incisor line, including one stricture directly located at the cricopharyngeus muscle. Prior to the placement of the biliary stent, 4 patients with strictures underwent a mean of 3 dilations (SD 2.4) over an average of 9.5 months (range 1-34 months). All placed biliary stents were fully covered self-expandable metal stents (SEMS), four 10x80mm and one 14x100mm. Two of the four strictures were dilated immediately prior stent placement to 12mm. Two patients with strictures were not dilated and stent was placed as only intervention, similar to the patient with the anastomotic fistula, whose biliary stent was fixed with Endostitch given high risk of stent migration. Stents were left in place for 2-8 weeks.Mean follow up after index procedure was 1.5 months (range 0.5-3 months). All 4 strictures recurred. Patients required a mean of 2.2 dilations. Dysphagia score decreased from a median of 3 to 1. The anastomotic fistula was noted to be resolved at the time of stent removal however the fistula in conjunction with the esophageal stricture persisted and resolved at a later point following www.giejournal.org Vol another stent placement.No immediate complications were recorded following biliary stent placement. Two stents however migrated after an average of 57 days.Limitations: Single center, retrospective study, small sample size, heterogeneous cohort. Conclusion: Complex proximal esophageal strictures are particularly complicated to treat. The innervation of the squamous epithelium of the proximal esophagus creates significant discomfort following placement of regular esophageal stents. This pilot study showed that biliary stents were well tolerated, however associated with a complication rate of 20% (migration). Tu1617 A Comparison Between Endoscopic Ultrasound Guided Rendezvous and Percutaneous Biliary Drainage After Failed ERCP for Malignant Biliary Obstruction Jason Bill*, Michael Darcy, Larissa L. Fujii-Lau, Daniel Mullady, Srinivas Gaddam, Faris Murad, Dayna S. Early, Steven A. Edmundowicz, Vladimir M. Kushnir Washington University St. Louis, St Louis, MO Background: Selective biliary cannulation is unsuccessful in 5-10% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard. However, endoscopic ultrasound guided rendezvous (EUSr) techniques have also been used for biliary decompression in this patient population. Aims: To compare 1) the initial success rate, 2) long term efficacy, and 3) safety of PBD and EUSr in relieving MDBO after failed ERCP. Methods: A retrospective study involving 50 patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008-2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002-2008). All EUSr procedures were performed by one of five endoscopists expert in ERCP and EUS. EUSr was performed via puncture of the common hepatic duct, followed by advancement of a guide wire into the biliary tree in an antegrade manner. EUSr was defined as successful if the wire could be advanced into the duodenum via the major papilla and a stent placed in a retrograde manner. Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates (early!7 days and late O7 days) after biliary decompression. Results: The mean age at presentation was (66.3 12.6 years), 27 (56%) patients were female. The etiology of MDBO was pancreaticobiliary malignancy in 42 (84%) and metastatic disease in 8 (16%) cases. There were no significant differences in any of the baseline characteristics between the two groups (table 1). Biliary drainage was technically successful by EUSr in 19 (76%) cases and by PBD in 25 (100%) (pZ0.002). In cases where EUSr was unsuccessful, biliary drainage was obtained by PBD (nZ3), repeat ERCP (nZ2) and EUS-guided choledochoduodenostomy (nZ1).Early adverse events occurred in 4 (16%) patients in the EUSr group and 3 (12%) in the PTBD groups (pZ0.68). Delayed adverse events occurred in 3 (12%) patients in the EUSr group and 6 (25%) in the PBD group (pZ0.27). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (pZ0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (pZ0.001). Conclusion: EUSr is a safe and effective method of biliary drainage in patients with MDBO after failed ERCP. Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions than those undergoing PBD. In experienced hands EUSr should be the initially attempted method of biliary decompression after failed ERCP.