S1666 EUS Choledochoduodenostomy: A Novel Way to Treat Recurrent Malignant Biliary Obstruction in the Setting of an Existing Biliary and Duodenal Stent

Abstract

Introduction: EUS-guided choledochoduodenostomy (EUS-CD) is an effective way to manage patients with malignant biliary obstruction and an inaccessible papilla. It involves creation of a fistula between the duodenal bulb and distal common biliary duct (CBD) using a lumen-apposing metal stent (LAMS). Data shows high technical and clinical success rates, with low adverse event rates and improved morbidity and mortality. Advantages of this approach include the ability to provide drainage to altered or inaccessible anatomy, and minimal invasiveness due to internalized drainage. We present a report of a patient with cholangitis due to recurrent biliary and gastric outlet obstruction (GOO) treated successfully with duodenal stenting and EUS-CD despite indwelling hardware. Case Description/Methods: A 71-year-old male with as history of locally invasive pancreatic adenocarcinoma presented with cholangitis and intolerance to oral intake. His prior course was complicated by GOO and biliary obstruction that required biliary fully covered self-expandable metal stent (FC-SEMS) and uncovered duodenal stent placement. Despite palliative chemotherapy, he presented 6 months later with cholangitis and imaging findings concerning for CBD stent occlusion, partial GOO and new ascites. Upper endoscopy showed significant stenosis within the duodenal stent that involved the major papilla, preventing conventional ERCP. The decision was made to evaluate for EUS biliary drainage. Presence of significant ascites precluded hepaticogastrostomy or gastrojejunostomy, however, there was an area superior to the indwelling biliary stent amenable to EUS-CDS. A 10mm x10mm LAMS was placed into the common hepatic duct with drainage of purulent fluid (Figure 1). Cholangiogram confirmed correct placement and excluded a leak. An uncovered duodenal stent was deployed through the indwelling duodenal stent and placement confirmed radiographically (Figure 1). The patient was discharged 2 days later with downtrending liver chemistries and tolerating oral intake. Discussion: Patients with combined malignant biliary and duodenal obstruction can be challenging to manage. Existing hardware complicates management even further. This case highlights the versatility of EUS biliary drainage allowing patient directed therapy with EUS-CDS in the setting of an existing biliary stent as an effective means of biliary drainage when ERCP was not possible.Figure 1.: A: occluded biliary stent B: LAMS with pigtail stents C: duodenal stent D: KUB showing stents in place.