Synchronous EUS-Guided Choledochoduodenostomy and Duodenal Stent Placement in a Patient with Malignant Papillary Tumor

Abstract

Purpose: Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for biliary drainage in patients with biliary obstruction from multiple etiologies. When ERCP is unsuccessful, the traditional alternatives are percutaneous transhepatic biliary drainage or surgical decompression. Some case reports have demonstrated successful EUS (Endoscopic ultrasound) guided choledochoduodenostomy accomplished through endoscopic placement of a biliary stent. We present a case of a malignant ampullary mass causing partial duodenal and complete biliary obstruction that was successfully treated with simultaneous EUS-guided choledochoduodenostomy and duodenal stent placement. Case: An 84 y/o Caucasian woman with history of malaise, abdominal fullness, weight loss, abnormal LFTs and biliary obstruction was referred for an ERCP. She had a history of ampullary adenocarcinoma and underwent local resection one year earlier followed by adjuvant chemo and radiation therapy due to tumor invasion of the head of the pancreas. An attempted ERCP failed to canulate the common bile duct (CBD) due to a large, fungating, ulcerated, circumferential mass which was partially occluding the second part of the duodenum. EUS showed dilation of the extra hepatic bile duct and irregular severe stenosis of the distal common bile duct. Under EUS-guidance, a duodeno-biliary fistula was created, the common bile duct was canulated through the fistula site and a Wallstent I fully covered biliary expandable endoprosthesis (60 cm in length and 80 mm in diameter) was placed after 30 seconds of balloon dilatation. The partially obstructed second part of duodenum was traversed with the endoscope and insertion of the Wallstent I uncovered enteric expandable endoprosthesis (90 cm in length and 22 mm in diameter) was accomplished. The patient had no complications and was discharged home after the procedure. Subsequently, EUS-guided celiac plexus neurolysis was performed to control the patient's abdominal pain. Conclusion: This case report elucidates a lesser invasive technique for treatment of malignant biliary and duodenal obstructions in the context of a failed ERCP. This procedure is more valid for end-stage malignancies where patients are wary of undergoing more invasive surgical therapies. No similar case has been reported in English literature for EUS-guided choledochoduodenostomy with simultaneous deployment of metallic biliary and duodenal stents in a patient with recurrent adenocarcinoma of the major papilla. With a good success rate and lesser morbidity and mortality compared to surgery, this procedure offers a plausible alternative for treatment of biliary and duodenal obstructions while long-term comparison studies are awaited.