Parameter EUS-CD, N  13 (%) EUS-HG, N  9 (%) EUS-AG, N  13 (%) P value, significance Complications 5/14 2/9 (22) 1/10 (10)  0.05, NS Major 0 1 - Biliary peritonitis 0 — Minor 5 4 - Self limiting peri-stent leak 1 - Hemobilia 1 - Self limiting peri-stent leak 1 - Long term stent occlusion — Procedure related mortality 0 1 0 — #- Intention to treat Su1565 EUS-Guided Choledochoduodenostomy or Hepaticogastrostomy to Malignant Distal Biliary Obstruction: a Prospective Comparative Trial Fernando Marson* 1 , Paulo Sakai 1 , Kiyoshi Hashiba 1 , Everson L. Artifon 1 1 Surgery Department, University of Sao Paulo Introduction: EUS-guided access to the bile duct is a novel technique that allows biliary drainage when standard ERCP is not feasible. When rendezvous procedure and/or anterograde interventions cannot be done as primary options, the alternative of creating a new fistula, a choledochoduodenostomy or hepaticogastrostomy can still be performed in selected patients. Aim: To compare the outcomes of two different drainage routes: choledochoduodenostomy and hepaticogastrostomy in selected patients that failed ERCP, rendezvous and anterograde intervention with distal malignant obstruction. Patients and Methods: Between April-2010 and July 2012 32 consecutive patients were elected to receive either a EUS-guided choledochoduodenostomy or EUS-guided hepaticogastrostomy. All patients had distal unresectable malignant biliary obstruction and had failed standard ERCP and EUS-guided rendezvous or anterograde intervention. Data including indications, success rate, technique, complications with a 3 month follow-up were prospectively collected in a database. All procedures were performed in a tertiary Endoscopic Unit. A partially covered SEMS (Boston Scientific, Wallflex,10 mm, 6 cm) was used in all procedures. After a EUS-guided bile duct puncture (choledochoduodenostomy) or a EUS-guided left hepatic duct puncture (hepaticogastrostomy) a cholangiogram was obtained followed by advancement of a 0,035 inch guide wire. Track dilation to allow passage of the stent delivery system was performed using a wire-guided needle-knife and bougies. Results: Thirty-two cases (15 hepaticojejunostomies and 17 choledochoduodenostomies) were performed. Indications for the procedure were pancreatic cancer (20 pts), extrinsic compression from metastasis (06) papillary tumor (02), neuroendocrine tumor (02), gallbladder cancer (01) and duodenal cancer (01). All patients were jaundiced and had both intra and extra-hepatic biliary dilation with elevated LFT‘s. Mean procedure time was 47 min. Three patients (2 choledochoduodenostomies and 1 hepaticojejunostomy) failed biliary drainage due to inability to advance the stent and were referred to surgery. Procedure success rate were similar in both groups: 93% for hepaticojejunostomy and 88% for choledochoduodenostomy. Immediate post-procedure complications occurred in 13% of the hepaticojejunostomy group (1 bleeding and 1 bacteremia) and 17% in the choledochoduodenostomy group (1 biloma, 1 bleeding and 1 stent migration). All immediate complications were successfully managed non- surgically except the stent migration. No late procedure related complications were found in both groups during the follow-up time. Conclusion: Statistical analysis revealed no difference in the procedure time (p=0,24), success and complication rate (p=0,766) in this series. More studies are warranted to clarify the role of each drainage route. Su1566 Endoscopic Ultrasound-Guided Antegrade Treatments for Biliary Disorders in Patients With Surgically Altered Anatomy Takuji Iwashita*, Ichiro Yasuda, Shinpei Doi, Shinya Uemura, Masatoshi Mabuchi, Tsuyoshi Mukai, Hisataka Moriwaki First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal and biliary anatomy is challenging even with an application of a double balloon or single balloon enteroscopy. Several EUS-guided biliary access techniques have been reported as effective alternatives. EUS-guided antegrade treatments (AG) have been developed more recently but have not yet been studied well. Aims: To evaluate the feasibility and safety of EUS-AG for biliary disorders in patients with surgically altered anatomies. Methods: We retrospectively identified all the patients for whom EUS-AG was attempted at our hospital between 4/2012 and 10/2012. EUS-AG was performed as follows: The left intra-hepatic bile duct (IHBD) was initially punctured from the intestine followed by cholangiography, antegrade guidewire manipulation and bougie dilation of the fistula. Either antegrade biliary stenting (ABS) with uncovered metallic stent or antegrade balloon dilation (ABD) was performed depending on the biliary disorders. In patients with stone, the stones were antegradely pushed out of the bile duct into the intestine, using a balloon. A naso-biliary drainage tube (NBD) was placed after ABD. Repeat ABD was performed if necessary. Results: EUS-AG was attempted in 7 patients, of whom 5 had choledocholithiasis, 1 had distal malignant biliary obstruction, and 1 had bilioenteric anastomosis stricture. EUS- AG was not performed in 1 patient because the results of the EUS and EUS- cholangiography did not indicate the presence of stones. In the remaining 6 patients, the IHBD was successfully punctured, followed by cholangiography, guidewire insertion, and bougie dilation. ABS for biliary obstruction and ABD were successfully performed in 1 and 5 patients, respectively. NBD was placed through the fistula after ABD and was removed after confirming the resolution of the biliary disorders. The cholangiography revealed residual stones, and antegrade procedures were repeated twice in 1 patient. Mild complications were observed in 2 patients. Conclusion EUS-AG for biliary disorders in patients with surgically altered anatomy is feasible. Further studies are warranted to confirm this finding. Su1567 EUS-Guided Biliary Drainage Is Effective, Safe, and Less Costly Than Percutaneous Transhepatic Biliary Drainage in Patients With Distal Malignant Biliary Obstruction and Failed ERCP Ali Kord Valeshabad*, Elham Afghani, Vikesh K. Singh, Payal Saxena, Marcia I. Canto, Anthony N. Kalloo, Mouen Khashab Johns Hopkins Medical Institute, Baltimore, MD Background: Endoscopic retrograde cholangiography (ERC) is the method most commonly employed for palliation of malignant biliary obstruction. Percutaneous transhepatic biliary drainage (PTBD) and, rarely, surgical bypass are utilized following failed ERC. Endoscopic ultrasound-guided biliary drainage (EGBD) is an emerging less-invasive alternative following unsuccessful biliary cannulation. EGBD may be a safe alternative technique to PTBD in these instances. However, it is currently unknown how both techniques compare in terms of efficacy, safety and cost. Aims: To compare efficacy, safety, and procedural facility charges of EGBD to PTBD after failed ERCP in patients with malignant distal biliary obstruction. Methods: The endoscopy and billing databases at a tertiary center were searched for patients who underwent PTBD or EGBD for relief of distal malignant biliary obstruction after failed ERC between 1/2002 and 11/2012. At our center, EGBD was instituted in 2/2011 and all patients with failed ERCP were then referred initially for EGBD. EGBD and PTBD groups were compared for technical success (stent placement in desired location), clinical success (relief of biliary obstruction), adverse events, and charges. Adverse events were graded according to the ASGE lexicon’s severity grading system. The groups were compared using the Student’s t- test for continuous variables and the chi-square test for categorical variables. Results: A total of 67 patients (age 66.3yr, male 58%, pancreatic cancer 57%) with failed ERCP subsequently underwent EGBD (n=16) or PTBD (n=51). Baseline characteristics of both groups were equivalent. Technical success was achieved in 14 (87.5%) and 51 (100%) of EGBD and PTBD patients, respectively (p=0.01). Clinical success was more commonly achieved in EGBD group but difference was not statistically significant (100% vs. 92.7%, p=0.30). Rate of adverse events was also equivalent between both groups (25.0% vs. 41.2%, p=0.36). Adverse events were rated as mild (n=2) or moderate (n=2) in the EGBD group and mild (n=9) or moderate (n=12) in the PTBD group. Survival was equivalent between both groups. Reinterventions (stent exchange/upsize/cleaning) were significantly more common in the PTBD group (92.2% vs. 25%, p0.001). Likewise, number of reinterventions per patient was significantly higher in the PTBD group (5.6 vs. 0.25, p0.001). Total procedural facility charges ($) (index procedure and reinterventions) was also significantly higher in the PTBD group (9030 vs. 4300, p=0.001). Conclusion: EGBD and PTBD are both safe and effective techniques for treatment of distal malignant biliary obstruction after failed ERCP. EGBD, however, is associated with significantly less charges due to the need for fewer reinterventions. These intriguing results suggest that EGBD should be the technique of choice for treatment of these patients. Su1568 EUS-Guided Gallbladder Drainage With Lumen-Apposing Metal Stents vs Percutaneous Transhepatic Approach for Acute Cholecystitis: a Mid-Term Comparative Analysis of Efficacy and Safety Carlos De La Serna*, Lorena Sancho Del Val, Irene PeñAs, Rafael Ruiz-Zorrilla, Alba L. Vargas, Noelia Alcaide, Pilar Diez-Redondo, Paula Gil-Simon, Manuel Perez-Miranda Endoscopy, Rio Hortega Hospital, Valladolid, Spain Background & Aims: Percutaneous transhepatic gallbladder drainage (PTGBD) is Abstracts AB370 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013 www.giejournal.org