Simultaneous duodenal metal stent placement and EUS-guided choledochoduodenostomy for unresectable pancreatic cancer with malignant duodenal and biliary obstruction

Patients with pancreatic cancer were not infrequently suffered from both biliary and duodenal obstruction. For such patients, both biliary and duodenal self-expandable metal stent placement were necessary to palliate symptoms. Recently, EUS-guided choledochoduodenostomy (EUS-CDS) was reported to be effective for patients with inaccecible to papilla due to tumor invasion. Here, we report two cases of pancreatic cancer with both biliary and duodenal malignant obstruction successfully treated with simultaneous duodenal metal stent placement and EUS-CDS using 7Fr Amsterdam type plastic stent. First case was a 74-year-old man with pancreatic cancer who was presented with jaundice and appetite loss. A duodenoscope revealed that papilla was invaded with tumor and duodenography showed severe stenosis in the horizontal portion. After duodenal uncovered metal stent was placed across the duodenal stricture, EUS-CDS was performed at the duodenal bulb. Second case was a 63-year old man who was previously placed covered metal stent for malignant biliary obstruction due to pancreatic cancer. He had been suffering from recurrent cholangitis due to duodenal obstruction. After removing previously placed biliary metal stent, EUS-CDS was performed at the duodenal bulb. Then, duodenal covered expandable metal stent was placed across the duodenal stenosis. Both patients could tolerate a regular diet and did not suffer from stent occlusion. About 30% of duodenal obstruction was concomitant with biliary obstruction in patients with pancreatic cancer, in which it was difficult to cross two metal stents. Although EUS-CDS was a novel technique and specialized device development was necessary, EUS-CDS combined with duodenal metal stent placement may be an ideal treatment strategy in patients with pancreatic cancer with both duodenal and biliary malignant obstruction.