Combined Single Session vs Sequential EUS and ERCP for the Diagnosis and Management of Pancreatic Ductal Adenocarcinoma (PDAC) with Biliary Obstruction

Introduction: Pancreatic duct adenocarcinoma (PDAC) often presents with malignant biliary obstruction. Obstruction is a barrier to the initiation of therapies for PDAC. EUS-FNA and ERCP are complimentary procedures for tissue diagnosis and decompression. While EUS-FNA ideally occurs prior to ERCP to justify deployment of metallic biliary stents, combined EUS/ERCP at same session increases anesthesia time and may translate to increase risks for complications. While prompt and convenient for patients, combined EUS/ERCP is of unclear clinical benefit. No comparative data exists on the ideal initial approach for timing EUS-FNA and ERCP for PDAC. Methods: All patients undergoing ERCP +/- EUS at Indiana University Hospital between 2010 and 2015 for biliary obstruction secondary to PDAC were retrospectively identified. Records were queried for demographics, sampling methods, accuracy, procedure efficacy and safety, duration, and long term patient outcomes. Based on index approach, patients were divided into three groups: Group A: Same session EUS-FNA and ERCP (EUS/ERCP), B: EUS-FNA followed by sequential subsequent ERCP (EUS then ERCP), and C: ERCP with or without sequential EUS (ERCP +/- EUS). The main outcomes measured were biliary stent failure, need for and number of subsequent procedures (ERCP, PTC, Surgery or tissue sampling), length of hospital stay, and time to initiation of therapy for PDAC. Results: Baseline characteristics are stratified by index procedure. (Table 1) ERCP/EUS equates to longer procedure duration without increased complications, differences in adequacy of EUS-FNA sampling, and ERCP failure. ERCP +/- EUS group more often underwent intra-ductal sampling (brushing, biopsies). However, 40% of these patients required subsequent EUS-FNA. EUS/ERCP patients were more likely to receive a metallic biliary stent (SEMS). To evaluate impact of EUS/ERCP as index procedure on outcomes, we analyzed patients with >60 days of follow up, not initially referred to hospice (Table 2). No differences were observed between approaches for stent failure or subsequent procedures. Evaluating EUS/ERCP vs sequential approach, median time to first PDAC treatment was less 3 days (p=0.05).Table 1: Baseline Patient Characteristics, Endoscopic, Anesthesia and Pathology Data (n=200)Table 2: Outcomes in Patients with Greater than 60 Days Follow-Up Data (n=126)Conclusion: Combined EUS/ERCP has comparable rates of complications, diagnostic and therapeutic success to a sequential approach and may expedite PDAC therapies. SEMS are often deployed in at EUS/ERCP, yet rates of stent failure are similar. Further studies are needed to assess relative cost and patient satisfaction.