An Alternative Modified Method of EUS-Guided Biliary Drainage in a Patient with Inoperable Cancer of Ampulla of Vater

Abstract

For a 54-year-old man with obstructive jaundice that was resulted from an inoperable cancer of Vater's ampulla, we established percutaneous transhepatic cholangeal drainage (PTCD) first and conducted endoscopic drainage for fears of mal-nutrition and dehydration. Endoscopic retrograde cholangiopancreatography (ERCP) failed in biliary cannulation and endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was performed. For difficulty in securing the scope in bulb due to luminal deformity and some expected following benefits, we advanced the scope into the second portion of duodenum and made a successful puncture into bile duct. A partially covered metal stent was inserted through the wall of second portion of duodenum into the bile duct. Such stent position was thought to avoid risks as sump syndrome or food occlusion, while most of the reported cases were managed with plastic stents through choledochogastrostomy or choledochoduodenostomy in the duodenal bulb. And a partially covered metal stent was thought to be with lower risk of migration. The patient discharged without a PTCD tube and started receiving palliative chemotherapy three weeks after the endoscopic treatment. We had learned from this case that EUS-CDS through the second portion of duodenum is feasible and may carry more benefits than that through the bulb or stomach, which was conducted in most previously reported cases.