2179 Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent

Abstract

INTRODUCTION: The incidence of pancreatic cancer has increased in the last decade. There have been improvements in pancreatic cancer through a multidisciplinary approach including chemotherapy, surgery, and radiation. The Whipple procedure is the mainstay operation for pancreatic head tumors; however, long term complications include cholangitis and pancreatitis. Cholangitis can be managed with drainage or stenting. Although PTC stent allows for drainage of the biliary system, an obstruction may call for internal stent placement. This case highlights placement of a stent using a pre-existing PTC drain for guidance. CASE DESCRIPTION/METHODS: A 71-year-old Caucasian male with history of pancreatic cancer status post a Whipple and chemoradiation presented with obstructive jaundice. EGD demonstrated a malignant stricture of the afferent jejunal limb. Attempted endoscopic stenting was unsuccessful. An 8.5 Fr PTC with internal and external biliary drainage catheter was performed by IR with the internal drainage catheter placed beyond the stricture. The patient over the course of the next month had decreased output from his biliary drain and was re-admitted with increased bilirubin and leukocytosis. The external/internal biliary drain catheter was replaced without significant improvement. A repeat EGD and ERCP demonstrated a PTC drain in the afferent jejunum and using a biliary wire through the side hole of the PTC drain, the PTC drain was removed over the wire. An uncovered metal stent was placed across the afferent jejunal stricture into the normal jejunal limb. Post procedurally the patient had improved LFTs. However, the patient had an interval rise in bilirubin and ALP. EGD demonstrated a clogged stent and a pigtail plastic stent was placed through the preexisting metal stent to prevent recurrent clogging. After the patient had improvement in his LFTs. DISCUSSION: Management of biliary obstructions requires biliary drainage with either a stent or surgical drainage. This case highlights a multi-step approach for management of a malignant biliary obstruction. After identifying an obstruction, an internal metal stent was placed in a rendezvous approach. Endoscopic metallic stent placement is a common for malignant biliary obstructions in jaundiced pancreatic cancer patients. In an event of an occluded metal stent, placement of a plastic stent is effective for management. This patient had a biliary obstruction after metallic stent placement prompting placement of a plastic pigtail stent within the metal stent.