ROLE OF ENDOSONOGRAPHY-GUIDED CHOLANGIOPANCREATOGRAPHY AFTER FAILED ERCP: CUMULATIVE EXPERIENCE FROM A SINGLE CENTER

Aims In cases of failed ERCP, the endosonography-guided cholangiopancreatography (ESCP) has positioned as an effective alternative comparable to the percutaneous approach. Furthermore, in several tertiary centers, the EUS and ERCP combination in a single procedure, is a well-accepted routine strategy. Main aims were to report a cumulative experience of ESCP from a referral center, with the purpose to assess:

1. the ESCP role over the total ERCPs cases;

2. general outcomes as technical, clinical success and safety.

Methods This is a single-center retrospective cohort analysis. Period: October2010 - October2019. Technical success for Rendez-Vous (RV, papilla identification/cannulation); and transmural drainage (successful stent placement). Clinical success for tumoral jaundice (> 50% bilirubin decrease after 4 weeks); for choledocholithiasis (cannulation and stones clearance); and chronic pancreatitis (significant pain improvement after 4 weeks). Failed RV cases were crossed to transmural/anterograde with intention to treat.

Results A total of 233 combined procedures (EUS+/-ERCP) were performed of 6480 scheduled ERCP procedures (3.6%). Detailed revision of 85 ESCP (1.3%) was done. EUS-guided pancreatography (n=16) and cholangiography (n = 67) in 100% of cases. Technical and clinical success rates were 90.5% and 80% respectively. EUS-guided RV (n=32) technically successful in 30% and 72% of pancreatic and biliary procedures respectively. In 12 failed RV were crossed to direct interventions. Transmural interventions (n=69) included pancreaticogastrostomy/duodenostomy (n=11), choledochoduodenostomy (n=32), hepaticogastrostomy (n=9) and anterograde stent (n = 2). Procedure related adverse events (21.2%) were more frequent (p< 0.05) and severe (p< 0.05) in malignant biliary pathology. Late stent dysfunction in 3 cases. Five procedure-related deaths related to procedures were detected.

Conclusions ESCP has a role reserved for a minority of selected cases with failed ERCP. It helps to improve the global efficacy of endoscopy drainage, but is not an adverse event free procedure, especially in malignant biliary pathology, and should be reserved in referral centers.