Abstracts

36, abscess 15, necrosis 9). Technical success was 95% (57/60): failures were due toinability to drain thick necrotic PFC in 2 and inability to visualize PFC in 1.Treatment success was 93% (53/57): 3 abscesses and 1 necrosis required surgery. Nocomplications were encountered. There were no significant differences in patient/clinical characteristics between group A and B patients. While there was nodifference in technical or clinical outcomes, median procedural duration wassignificantly shorter for group B than group A patients (25 vs.70 min; p ! 0.001).After 25 procedures, procedural duration for performing EUS-D of PFC was morelikely to be ! 30 minutes (adj. OR Z 11.6; p Z 0.01) even after adjusting forpatient age, serum albumin, type/location/size of PFC, drainage modality (stent vs.stent plus drainage catheter) and site of endoscopic access in GI tract forestablishing drainage. Conclusions: In this study, the largest reported to-date, EUS-guided drainage of PFC was performed safely using the graded dilation techniquewith a successful outcome in a majority of patients. Learning curve, with regard toprocedural duration, improved significantly after the first 25 cases.

M1494

EUS-Guided Drainage: An Alternative to Surgical and

Percutaneous Approaches for Management of Multiple,

Non-Communicating Peripancreatic Fluid CollectionsShyam Varadarajulu, Jeanetta BlakelyBackground: Management of multiple peripancreatic fluid collections (PFC) isa therapeutic challenge, particularly in patients with disrupted main pancreatic ductas pancreatic stenting is not feasible. Also, endoscopic trans-mural drainage maynot be feasible as none or only few of the PFC may cause definitive luminalcompression (LC). Under such circumstances, management is relegated topercutaneous/surgical drainage. Although the role of EUS for drainage of PFCwithout LC is well known, there are no published reports on use of this modalityfor drainage of multiple PFC. Aim: Evaluate the role of EUS in drainage of multiple,non-communicating PFC. Methods: Prospective study of all patients whounderwent EUS-guided drainage of PFC over a 42-month period. Prior to EUS, allpatients underwent contrast enhanced abdomen CT and ERCP was attempted forpancreatic stenting. In symptomatic patients with multiple PFC that were non-communicating, not causing LC, and large (O 6 cm), EUS-guided drainage of PFC inall locations was undertaken. At EUS, the PFC were accessed using a 19-gaugeneedle and after passage of a 0. 035 inch guidewire, sequential dilation of the tractwas performed and 7 Fr/10 Fr stents or drainage catheters were deployed. Clinicalfollow-up and CTwas undertaken at 6-weeks to assess treatment response. Results:Multiple, large, non-communicating PFC was encountered in 6 (3 pseudocyst, 2abscess, 1 necrosis) of 60 patients (10%; 95% CI [4.3%, 20.4%]) who underwentEUS-guided drainage. Etiology of pancreatitis in the 6 patients (3 female, mean age60.5yrs [range, 41-70]) were idiopathic in 4, gallstone 1 and ETOH 1. ERCP revealedcomplete duct disruption in all 6 patients. Three patients with pseudocyst had PFCat 3 locations and others at 2 locations. The procedure was technically successful inall patients (100%). A total of 15 PFC sites were drained under EUS-guidance inthese 6 patients. Sites of access were GE junction in 1, gastric cardia/fundus (6),greater curvature (2), antrum (2), duodenum (3), and Roux-en-Y loop in (1). Themean procedural duration was 60 minutes (range, 47-76). No complications wereencountered. At follow-up, 4 (3 pseudocyst, 1 abscess) of 6 patients (66%) hadcomplete symptom relief and resolution of PFC; others experienced persistentsymptoms with residual fluid collection requiring surgical drainage. Conclusions:EUS-guided drainage of multiple, non-communicating peripancreatic fluidcollections is technically feasible, safe, obviates the need for surgery or placementof multiple percutaneous drainage catheters, and leads to a successful clinicaloutcome in two-thirds of patients.

M1495

EUS Versus Surgical Cyst-Gastrostomy for Management

of Pancreatic PseudocystsShyam Varadarajulu, Tercio Lopes, Charles M. Wilcox,Ernesto R. Drelichman, Meredith L. Kilgore, John D. ChristeinBackground: Although EUS-guided cyst-gastrostomy is increasingly performed,there are no studies comparing the clinical outcomes and cost-effectiveness of thisapproach with ‘gold standard’ surgical cyst-gastrostomy. Aim: Compare the clinicaloutcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy formanagement of patients with pancreatic pseudocysts and perform a cost analysis ofeach treatment modality. Methods: This is a retrospective case-control study ofconsecutive patients with uncomplicated pancreatic pseudocysts who underwenteither surgical or endoscopic cyst-gastrostomy over a 3-yr period at a tertiaryreferral center. Individual patients who underwent surgical cyst-gastrostomy werematched with two patients who underwent EUS-guided cyst-gastrostomy duringthe same time period for age, etiology of pancreatitis, and size of the pseudocyst.All procedures were performed by one experienced pancreaticobiliary surgeon andone experienced endosonographer. Patients with pancreatic abscess or necrosiswere excluded. Main outcome measures were rates of treatment success,complications and reinterventions, length of hospital stay (post-procedure), andcost associated with each treatment modality. Treatment success was defined asresolution of clinical symptoms and pseudocyst on follow-up imaging at 6-weeks.Results: Ten patients (6 male, median age 41yrs, mean pseudocyst size 6.2 cm

AB226 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008

[range, 5-16]) who underwent surgical cyst-gastrostomy were matched with 20patients who underwent EUS-guided cyst-gastrostomy. There were no significantdifferences in demographic data, comorbidity, and clinical characteristics betweenboth groups. While there were no significant differences in rates of treatmentsuccess (100% vs. 95%; p Z 0.36), procedural complications (none in both groups)or reinterventions (10% vs. 0%; p Z 0.13) between surgery vs. EUS-guided cyst-gastrostomy, the mean length of hospital stay for EUS-guided cyst-gastrostomy wassignificantly shorter than for surgical cyst-gastrostomy (2.6 vs. 6.5 days; p Z 0.008).The average total cost per case for the EUS-guided cyst-gastrostomy approach wassignificantly less when compared to surgical cyst-gastrostomy ($7943 vs. $14,815,p Z 0.01) with the total cost savings being $6872 per patient. Conclusions: Whenavailable, EUS-guided cyst-gastrostomy should be the first-line treatment approachfor patients with uncomplicated pancreatic pseudocysts as the procedure isless costly and is associated with shorter length of hospital stay than surgicalcyst-gastrostomy. There was no significant difference in clinical outcomes betweenboth treatment modalities.

M1496

One-Step, EUS-Guided Drainage of Pancreatic Pseudocysts:

Experience in 52 PatientsColin Mckay, Simon Denley, Ross CarterIntroduction: In the treatment of pancreatic pseudocysts endoscopic treatment isnow standard. Increasingly, trans-gastric drainage is being used in patients withacute pancreatitis and patients with more complex cysts containing debris. Wereport our experience in 52 patients using a one-step, two stent procedure underEUS guidance. Methods: All patients had persistent, symptomatic cysts. Aetiologywas acute pancreatitis in 34 and chronic pancreatitis in 18 patients. 17 cysts wereinfected. ERCP or duct stent placement was either unsuccessful (8 cases) ordemonstrated no communication (31 cases). In 10 cases ERCP was not attempted.In the remaining 3 cases, cysts persisted despite pancreatic duct stenting. Cystdrainage was carried out under EUS control using a therapeutic echoendoscope(Pentax EG-3830UT) with a 3.8 mm working channel and bridge. Two or morepigtail stents were inserted after entering the cyst with a Wilson-CookCystotomeTM and performing balloon dilatation (oesophageal balloon) of thecystgastrostomy to 12-15 mm. Results: Cysts resolved at the first procedure in 37cases, with one patient undergoing 24h of lavage via a naso-cyst catheter. A further5 patients underwent a second procedure, 3 for placement of a naso-cyst catheterand lavage, 2 for further dilatation of the cyst-gastrostomy. All 5 resolved aftera second procedure. One patient underwent 4 procedures, a naso-cyst catheter atthe first followed by 3 further dilatations. In 3 patients formal open surgery wasrequired, one 2 months later for incomplete drainage, the other two for procedurerelated complications. Two patients died following surgery for persistent, infectedcysts. A third death occurred due to liver failure following successful cyst drainageand a fourth died approximately 1 year after successful cyst drainage froma pancreatic tumour. Conclusions: One-step EUS-guided drainage with thedeployment of two or more stents is an effective treatment with 43 of 52 patientshaving complete cyst resolution by endoscopic means only. Complications alloccurred early in this study indicating a learning curve, but these can be minimisedby appreciating the need for further intervention and the use of naso-cyst lavage inmore complex cysts.

M1497

Effectiveness and Safety of EUS Guided Pancreatic Pseudocyst/

Abscess Drainage: A Systematic Review of Prospective StudiesPriyanka Tiwari, Nadim S. Jafri, Praveen K. Roy, Mainor R. AntillonBackground: EUS guided pseudocyst and abscess drainage has been reported sinceit was first described in 1992. Overall success rates and complications of thisprocedure are however not known and it is unclear if this treatment is definitive.We conducted a systematic review to evaluate the effectiveness and safety of EUSguided drainage of pancreatic pseudocysts and abscesses. Method: We performeda systematic search of Medline, EMBASE, and Cochrane Central Register of ControlledTrials without language restriction for prospective studies evaluating the role of EUSguided drainage of pancreatic pseudocysts/abscess. We also hand searched greyliterature from major gastrointestinal meetings. Standard forms were used to extractdata regarding study design, cyst/abscess size, success rates, recurrence, surgicalintervention, mortality and complications by two independent reviewers. Result: Sixstudies (156 patients) met our predefined eligibility criteria. The sample size of thestudies ranged from 8 to 46 patients. Patient age ranged from 9-81 years. Time ofintervention from time of diagnosis was less than 4 weeks. The length of follow-upperiod after the therapeutic intervention ranged from 3-468 weeks among the studies.The etiology of cyst/abscess formation reported in the studies were: alcohol, acutepancreatitis, gallstones and other causes. The size of the pseudocysts/abscess rangedfrom 4-14 cm in all the studies. The pancreatic body was the most common location(22-76% of patients), followed by the head of the pancreas (12-52%) and pancreatictail (8-34%). In two prospective studies, 3-8% patients were also found to have gastricvarices at the time of endoscopy. An endoscopic bulge was seen in 3-12% patients (3studies). Overall, the success rate for EUS guided drainage of pancreatic pseudocystsand abscesses varied from 82%-100% among the studies. The most commoncomplications from the endoscopic intervention were bleeding, perforation, stentmigration and stent occlusion. The rate of recurrence of the pesudocyst/abscess

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