Sa1535 Dual Modality Drainage of Infected Walled off Pancreatic Necrosis Is Associated With Reduction in Resource Utilization Over Standard Percutaneous Drainage Michael Gluck*, Andrew S. Ross, Shayan Irani, S. Ian Gan, Richard a. Kozarek Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA Background: Infected walled off pancreatic necrosis (IWOPN) is generally considered an absolute indication for drainage and/or debridement. Our group has previously demonstrated superior clinical outcomes and decreased resource utilization with combined endoscopic and percutaneous drainage (DMD) of infected and symptomatic walled off pancreatic necrosis in comparison to standard percutaneous drainage (SPD). We sought to compare our experience with DMD to that with SPD for patients with IWOPN alone. Methods: We reviewed an IRB-approved, prospective database of all patients with WOPN treated with either SPD or DMD between 1/1/2006 to 11/24/2012. If the initial gram stain and culture at the time of drainage was positive, patients were labeled as having IWOPN and included in this analysis. Results: During the study period, 98 patients were treated with DMD and 44 with SPD for WOPN of whom 47 (48%) and 19 (41%) had IWOPN respectively. Mean age, male preponderance, majority with gallstone etiology and computed tomographic severity indices (CTSI) were statistically identical (See Table). DMD treated patients with IWOPN had statistically reduced length of hospitalizations (LOH) (24 v 63 days, p0.004), use of radiological resources (p0.002), and ERCP’s (p0.01). Removal of drains was achieved earlier in the DMD cohort (83 v 158 days, p0.05). There were 4 patients who bled from pseudoaneurysms in the SPD cohort (21%) and 1 in the DMD treated group (2%, p0.001). Three patients had surgery for either fistulae or debridement (16%) in the SPD group versus none in the DMD cohort. Two patients with DMD had surgery for chronic pain over one year after removal of external drains. There were 2 deaths in each cohort in patients who had external drains in place (not completed therapy). Conclusions: In patients with IWON, DMD resulted in decreased length of hospitalization as well as decreased utilization of radiologic, surgical and endoscopic resources as compared to SPD. These data further support DMD as the treatment of choice for patients undergoing percutaneous drainage of IWOPN. Age mean % male mean CTSI CBD stones LOH mean CT# mean ERCP# mean Drains# Mean Mean Time to Drain Removal (days) SPD infected 56 58 7.3 58% 63 15 2.5 2.7 158 DMD infected 60 73 8.2 47% 23 7 1.4 1.4 83 p value 0.33 0.26 0.13 0.41 0.004 0.002 0.01 0.001 0.05 Sa1536 A Meta-Analysis Comparing Transmural and Transpapillary Approaches of Endoscopic Pancreatic Pseudocyst Drainage: Is a Preferred Method Emerging? Shounak Majumder*, William L. Baker, John W. Birk University of Connecticut Health Center, Farmington, CT Background: Endoscopic drainage of pancreatic pseudocysts is a widely accepted treatment modality. It can be performed by either a transmural or transpapillary approach or both. Traditionally, the transmural route has been considered to be technically more challenging and associated with a higher rate of complications. Although multiple studies have reported outcomes in patients undergoing endoscopic pseudocyst drainage, very few have directly compared the transmural versus transpapillary approaches. Methods: We searched MEDLINE and SCOPUS from January 2000 through June 2012 for clinical studies comparing outcomes of transmural versus transpapillary drainage of pancreatic pseudocysts. We chose 2000 due to the mainstream adaption by then of therapeutic EUS for the transmural approach. Outcomes investigated included technical success, clinical success, pseudocyst recurrence at 30 days, procedural complications, bleeding, and post-procedural infections. Pooled odds ratios (ORs) and corresponding 95 percent confidence intervals (CI) were calculated using a DerSimonian and laird random-effects model. Statistical heterogeneity and publication bias were addressed using the I2 statistic and Egger’s weighted regression statistics, respectively. Results: A total of 606 studies were screened and 17 studies evaluated for eligibility. Of these, a total of 212 patients from 4 studies were analyzed. In this meta-analysis no difference was seen between a transmural and transpapillary approach in terms of technical success (OR 2.06, 95% CI 0.54 - 7.86), clinical success (OR 1.03, 95% CI 0.33 - 3.27), recurrence (OR 0.33, 95% CI 0.09 - 1.20) or major complications like bleeding (OR 0.73, 95% CI 0.16 - 3.33) and infection (OR 1.34, 95% CI 0.34 - 5.33). No statistically significant heterogeneity or publication bias was seen for any outcomes. Recurrence rate did favor transmural approach and was approaching significance at P value =0.09. Conclusion: Endoscopic drainage of pancreatic pseudocysts is safe and effective by either a transmural or transpapillary approach. Our analysis did not support the commonly held belief of a higher complication rate and lower rate of technical success with the transmural approach. Also, our study hints at a lesser recurrence rate with the transmural approach. With technical advances and increasing availability of endoscopic ultrasound and new equipment designed to facilitate the transmural route it may become the preferred approach in the near future. Additional head-to-head comparative studies of these treatment strategies are needed. Sa1537 Outcomes of Endoscopic Ultrasound Guided Drainage of Pancreatic Pseudocysts With Debris Using Combined Endoprosthesis and Nasocystic Drain Harkirat Singh 1 , Anna Strongin 1 , John Dewitt 2 , Ali Siddiqui* 1 , Jordan Smoker 1 , Thomas E. Kowalski 1 , David E. Loren 1 , Mohamad a. Eloubeidi 3 1 Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA; 2 Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN; 3 Gastroenterology, American University of Beirut, Beirut, Lebanon Background and Aims: Debris within the pseudocyst may impair success of endoscopic drainage. The aim of our study was to compare the clinical outcomes and complications of endoscopic ultrasound (EUS) guided pseudocyst drainage with and without a nasocystic drain for the management of pancreatic pseudocysts with and without viscous solid debris-laden fluid. Methods: We conducted a retrospective study at a tertiary-referral center of all patients who had undergone EUS guided drainage of symptomatic pancreatic pseudocysts between October 2000 and January 2012. Patients were divided into 3 groups: a) those without debris that underwent drainage via stents alone (n=45); b) those with solid debris that underwent drainage via a nasocystic drain alongside stents (n=63); and c) those with solid debris that underwent drainage via transmural stents only (n=24). All patients were evaluated with an abdominal CT at 1 and 6 months after pseudocyst decompression. Stent removal was undertaken if complete cyst decompression was achieved. The outcomes measured in the study were short-term success (30% decrease in pseudocyst size at 1 month), long-term success (complete pseudocyst resolution on 12 month follow-up), procedure-related complications, and reinterventions. Results: The patients with viscous solid debris-laden fluid whose pseudocysts were drained by both stents and a nasocystic tube had a three times greater short term success rate compared to those that were drained by stents alone (P = 0.03). On 12 month follow-up, complete resolution of pseudocysts with debris drained via stents alone was lower (58%) compared to those with debris who underwent drainage via a nasocystic drain alongside stents (79%; p=0.05) and in those without debris (78%; p= 0.1). Stent occlusion was higher in cysts with debris drained by stents alone (33%) compared to those drained via a nasocystic drain alongside stents (13%; P = 0.03). Pseudocysts with debris that were drained by both stents and a nasocystic tube had a greater short (OR = 3.6) and long term (OR= 2.7) success rate compared to those that were drained by stents alone. These findings are summarized in Table 1. Conclusions: In patients with pseudocysts with viscous debris-laden fluid, EUS-guided drainage using a combination of a nasocystic Abstracts AB242 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013 www.giejournal.org