S1136 Endoscopic Ultrasound Guided Biliary Drainage and Percutaneous Transhepatic Biliary Drainage Provide Successful Salvage Biliary Drainage in Biliary Obstruction From Pancreatic Cancer: A Single Center Experience

Introduction: Biliary obstruction is common in patients with pancreatic cancer.Approximately 70% of patients present with an obstruction.Endoscopic retrograde cholangiopancreatography(ERCP) is the primary modality for biliary decompression.Alternative nonsurgical methods include endoscopic ultrasound guided biliary drainage (EUSBD)via choledochoduodenostomy and percutaneous transhepatic biliary drainage(PTBD).Our studies objective is to review the rates of technical and clinical success of EUSBD and PTBD for malignant biliary obstruction after unsuccessful ERCP Methods: A retrospective study was performed from 2017-2021,including patients with biliary obstruction from pancreatic head mass who underwent ERCP,EUSBD,or PTBD.Technical success was defined by successful biliary decompression with either ERCP,EUSBD or percutaneous approach.Clinical success was defined as a 25% reduction in total bilirubin 7 days post procedure Results: 309 patients were initially reviewed;26 patients excluded from the ERCP group,24 patients in EUSBD group, and 151 patients from the PTBD group for lack of pancreatic head mass or absence of pre/post-procedural labs.108 patients were included in the final data collection, and the demographics were comparable for 68 patients in ERCP group, 28 patients in EUSBD group, and 12 patients for PTBD.The mean pre-procedure total bilirubin 10.6 ERCP, 11.4 EUSBD, and 12.1 PTBD.In 29% of ERCP procedures, a biliary stent was not able to be placed due to luminal obstruction or failed biliary cannulation.Of the unsuccessful ERCPs, 19% were referred to PTBD, and 10% underwent EUSBD.Technical success was achieved in 92% and 86% for PTBD and EUSBD, respectively(p=0.61).In the EUSBD group, 11% of procedures had failed stent placement and were referred for PTBD.Clinical success was achieved in 85%of ERCP, 83%of EUSBD, and 91%of PTBD (p=0.73) (Figure) Conclusion: While ERCP is the initial treatment modality for biliary obstruction from pancreatic cancer, it can be challenging with a malignant luminal obstruction.Our study shows similar rates of technical and clinical success among the EUSBD and PTBD groups after unsuccessful ERCP.Our findings support the use of EUSBD over PTBD after unsuccessful ERCP since EUSBD can be performed in the same setting without need for another procedure.Further studies with more patients are needed to validate these findings, determine the tolerability of the two procedures to allow for a more personalized approach, and stratify predictors of technical and clinical success. (Table)Figure 1.: Flow chart demonstrating technical success of ERCP and subsequent EUSBD and PTBD procedures. Table 1. - Demographic data for ERCP, EUSBD, and PTBD groups ERCP n = 68 EUSBD n = 28 PTBD n = 12 Average age (years) 68 70 71 Males 56% 46% 42% Caucasian 72% 68% 75% African American 24% 32% 25% History of Smoking 47% 50% 50% CBD Diameter (mm) 12.8 15.4 11.6