HEPATICO-DUODENOSTOMY WITH A LUMEN-APPOSING METAL STENT (LAMS) TO ACHIEVE COMPLETE BILIARY DRAINAGE IN A METASTATIC BILATERAL HILAR STRICTURE

Retrograde complete biliary drainage by means of ERCP in complex hilar strictures is not always feasible. Metastasis to the liver often result in complex strictures. Chemotherapy usually requires adequate biliary drainage.

A 68 year-old male with metastatic colo-rectal cancer developed jaundice. A plastic biliary stent could only be inserted into the left bile-duct at ERCP. Persistent jaundice prompted repeat ERCP with failed right-sided access. Massively dilated right-hepatic-duct (RHD) was seen on EUS. Following 19G puncture, 0.025-inch guidewire placement, and serial graded dilation, an 8 × 8-mm LAMS was placed without any cautery, to avoid thermal injury to the nearby hepatic artery. To prevent LAMS disfunction following bile-duct decompression, two 7F double pig-tail stents were placed through the biliary LAMS in opposite directions. No complications ensued. The patient cleared his jaundice and he could resume chemotherapy.

Our case illustrate complete biliary drainage by means or ERCP combined with EUS-guided biliary drainage, used in a complementary fashion. Access to multiple branches close to the hilum prevented standard tubular self-expandable metal stent insertion, to prevent contralateral blockage. A LAMS could be used for intrahepatic biliary drainage thanks to favourable anatomy.