A 75-year-old woman was admitted to our hospital with obstructive jaundice. Abdominal
computed tomography revealed a hypovascular mass in the head of the pancreas, dilatation
of the bile ducts, and tumor invasion into the second portion of the duodenum ([Fig. 1]). Small nodules were also observed in the omentum, and a diagnosis of pancreatic
cancer with peritonitis carcinomatosa was made. After percutaneous transhepatic biliary
drainage (PTBD) was performed to relieve the jaundice, a duodenal self-expandable
metallic stent was deployed in the duodenal stricture ([Fig. 2]
, [3]). Informed consent was obtained, and then a convex linear-array echo endoscope (GF-UCT2000;
Olympus Co. Ltd., Tokyo, Japan) was used to puncture the dilated extrahepatic bile
duct at the level of the duodenal bulb with an Olympus KD-10Q-1 needle-knife, using
an electrosurgical generator (ICC200; ERBE, Tübingen, Germany). After the needle-knife
was removed from the catheter, a guide wire was introduced into the bile duct under
fluoroscopic guidance, and the catheter was removed. A 7-Fr biliary plastic stent
(Flexima; Cook Endoscopy, Winston-Salem, North Carolina, USA) was then inserted into
the left hepatic bile duct ([Fig. 4]). Once this procedure was complete, the PTBD catheter was removed ([Fig. 5]).
Fig. 1 Abdominal computed tomography showed a hypovascular mass in the head of the pancreas,
with tumor invasion into the second portion of the duodenum.
Fig. 2 Endoscopic examination also showed tumor invasion into the second portion of the duodenum.
Fig. 3 A duodenal self-expandable metallic stent was deployed in the duodenal stricture.
Fig. 4 A biliary plastic stent was then inserted through the choledochoduodenostomy into
the left hepatic bile duct.
Fig. 5 One week after insertion, endoscopic examination showed that there was effective biliary
drainage via the biliary plastic stent.
Endoscopic ultrasound-guided biliary drainage from the duodenal bulb has been reported
recently [1]
[2]
[3]. If a patient has both a distal biliary stricture and a duodenal stricture around
the major papilla, a biliary metallic stent can be deployed via the PTBD route. However,
and particularly in patients with peritonitis carcinomatosa, recurrent cholangitis
can occur because duodenal contents can reflux into the bile duct when a biliary metallic
stent is deployed beyond the major papilla [4]. As a result, patients can require external biliary drainage. We suggest that endoscopic
ultrasound-guided choledochoduodenostomy can be an effective treatment for patients
who have a duodenal stent over the major papilla and peritonitis carcinomatosa.
Endoscopy_UCTN_Code_CPL_1AH_2AD
Endoscopy_UCTN_Code_CPL_1AL_2AD
