GASTROYEYUNOSTOMY AND COLEDOCODUODENOSTOMY FOR BILIARY DRAINAGE IN PATIENT WITH DUODENAL AND BILIARY STENOSIS DUE TO PANCREATIC NEOPLASM

Introduction:

We describe a case of a 62-year-old man with a history of cholecystectomy due to repetitive biliary colic. The patient was diagnosed with locally advanced pancreatic adenocarcinoma cT4cN1M0, in the context of constitutional syndrome and obstructive jaundice. The pancreatic mass produced dilation of the intra and extrahepatic bile duct, as well as Wirsung (6.5 mm) and stenosis of the third duodenal portion. For this reason, we decided to do an endoscopic derivation of the bile and duodenal stenosis.

Short Description of the Technique: Due to the impossibility of passage the guidewire to the distal duodenum we could not put a duodenal prothesis. Because of that we decided to perform an endoscopic gastrojejunostomy and endoscopic biliry duct derivation, at the same procedure.

Firstly, we introduced the endoscopic ultrasound (EUS) in order to identify a loop of small intestine close to the stomach. Then, the bowel was punctured with a 19 G needle so as to introduce contrast and methylene blue in order to distended the loop. The endoscopic gastrojejunostomy was performed using lumen-apposing metal stent (LAMS) (HOT Axios 15 × 10 mm) by the "freehand" technique. After that, we verified the correct position in the jejunum by direct vision and seeing the exit of methylene blue to the stomach.

For the derivation of the biliary stenosis, we identifieded the dilated bile duct (2.6 cm) at the duodenal bulb level. Subsequently, we punctured it with a 19 G needle and passed a guidewire to the common bile duct. Finally, we performed a choledochoduodenostomy with 8 × 8 mm HOT Axios and verified its correct placement.

Conclusions:

The EUS allows the performing of the drainage of the biliary tract and the bowel stenosis at the same procedure, using lumen-apposing metal stent without complications.