RESCUE CHOLECYSTOGASTROSTOMY GUIDED BY ENDOSCOPIC ULTRASOUND FOR THE TREATMENT OF MALIGNANT OBSTRUCTIVE JAUNDICE AFTER ERCP AND FAILED RENDEZVOUS

Introduction:

The endoscopic treatment of choice of obstructive jaundice in patients with unresectable pancreatic neoplasia is the placement of a biliary prosthesis through ERCP. In cases in which the bile duct can not be cannulated, PTHC is often used. We present a case of obstructive jaundice resolved by EUS-guided cholecystoduodenostomy.

Clinical case:

A 77 year-old male was admitted due to obstructive jaundice. Percutaneous drainage is requested from interventional radiology, performing percutaneous cholecystostomy. Endoscopic ultrasound is requested, showing a pancreatic head neoplasm with hepatic metastases and vascular invasion. Fine needle aspiration confirms the diagnosis of adenocarcinoma. ERCP is requested for the placement of palliative biliary prosthesis. ERCP is performed without cannulation of the biliary tract. Rendezvous is attempted by puncturing a non dilated bile duct (5 mm) without getting a guidewire to pass through the papilla. Given the palliative nature of the treatment and the existence of percutaneous drainage to the gallbladder with permeability of the cystic duct, it was decided to reconvert the external drainage to an internal one by means of cholecystogastrostomy with Hot Axios prosthesis of 10 × 10 mm with “free hand” technique. Small-sized stones are removed by means of a cholecystoscopy through the prosthesis. Double pigtail prosthesis is left through the prosthesis and after 4 days the percutaneous drainage is removed, bilirubin normalized.

Conclusions:

Cholecystoduodenostomy/gastrostomy is feasible as a definitive rescue treatment for malignant obstructive jaundice in cases in which the cystic is permeable.