A Prospective Evaluation of Tandem EUS and ERCP as a Single Procedure

A Prospective Evaluation of Tandem EUS and ERCP as a Single Procedure Jake Matlock, Shawn Mallery, Rebecca Lai, Martin Freeman BACKGROUND: EUS and ERCP are complimentary procedures in the diagnosis and therapy of pancreaticobiliary disorders. While both may be performed as a single tandem procedure (TP), there have been concerns about the safety of ERCP following EUSwith FNA, despite few data.We hypothesized that TP would allow multiple modalities to be combined in a single procedure without conferring additional risk. METHODS: 30-day outcomes of TP were evaluated prospectively with complications defined byERCP consensus criteria. RESULTS: 130 consecutive patients underwent TP, with EUS performed first in 120 (92%). Sedation was by GI (24) or anesthesia (MAC 9, general 97). Primary indication was diagnosis/staging/treatment of suspected pancreatic/biliary tumor (47), ampullary tumor (7), suspected CBD stone (7), suspected SOD (23), acute recurrent pancreatitis (22), chronic pancreatitis (5), pseudocyst drainage (15), and other (4). EUSmaneuvers included FNA in 39 patients (30%) [pancreas (30), liver (6), lymph node (3), CBD (2) and/or ampulla (2) and celiac neurolysis (6)]. ERCP maneuvers included SO manometry (27), sphincterotomy (67 biliary, 35 pancreatic), biliary stent (27 plastic, 19 metallic), and pancreatic stent (53 plastic, 1 metallic). Combined EUS/ERCP maneuvers included pseudocyst drainage (15) and EUS-guided rendezvous ERCP for duct drainage (4). Following TP, pancreatitis occurred in 12 (9.2%), none severe, and all but 1 after high-risk therapeutic ERCP (including SOD and recurrent pancreatitis); rates of pancreatitis were similar with (3/39) vs. without FNA (9/91)(p=0.75). Perforation occurred after 2 transmural pseudocyst drainages (1 operated), but none undergoing FNA. 40 (31%) patients were discharged on the day of the procedure; median hospital stay was 1 day. In the 33 possible tumor cases that had FNA, intraprocedural cytologic analysis showed malignancy in 22 (67%); tumor was staged as unresectable in 16/22 (73%), allowing for metallic stent placement (16) and celiac neurolysis (6). All CBD and main PD stones, and all but one pancreas divisum found by EUS were confirmed and treated at ERCP. CONCLUSIONS: Tandem EUS and ERCP is relatively safe with no complications specifically attributable to performance of FNA during EUS. Combining procedures allowed multiple modalities for diagnosis, staging and definitive therapy such metallic stenting, celiac neurolysis and pseudocyst drainage to be performed during a single procedure.