Complex palliative treatment of an advanced inoperable tumor of the papilla of vater. endoscopic enteral and percutaneous biliary metalstent insertion

Abstract

Introduction: Malignant biliary obstruction usually occurs due to papillary-, pancreatic-, gallbladder- or bile duct tumors. Unfortunately, in the majority of cases, it is diagnosed lately, so curative surgery cannot be performed. The best palliative method to resolve jaundice is the placement of a biliary metalstent into the biliary tree to bridge the stenosis. Malignant gastric outlet obstruction can occur as a consequence of gastric/duodenal tumor, or due to expansion of pancreatic-, biliary- and papilla of Vater tumor to this region. In such cases, curative surgery is almost always impossible. Palliative methods can be surgical bypass, gastro-enteral anastomosis or most recently, self-expandable enteral stent. Case: A 87-old male was admitted to our department because of obstructive jaundice, weight loss and vomiting caused by an advanced tumor of papilla of Vater, diagnosed five months ago. Upper endoscopy revealed a tumorous stenosis in the duodenum that could not be intubated. A self-expandable enteral stent was placed through the stenosis. Two days later, after the full expansion of the metalstent, a duodenoscope was inserted into the duodenum through the stent to try to resolve biliary obstruction. As a consequence of advanced malignant process that involved the whole circumference of the duodenum, the papilla could not be recognized. Therefore, percutaneous transhepatic cholangiography was performed followed by insertion of biliary metalstent by percutaneous route. The patient was discharged without jaundice and with ability even to eat soft meals. Discussion: A good palliative treatment could be achieved by combination of operative endoscopy and invasive radiology.