Keywords
Cancer
-
endoscopic retrograde cholangiopancreatography
-
endosonography
-
stent
Introduction
Extrahepatic biliary obstruction is one of the common manifestations of malignancies
involving pancreatic biliary area of gastrointestinal tract, and it usually requires
palliation. The obstruction can be bypassed either by placing an endoprosthesis through
the papilla using endoscopic retrograde cholangiopancreatography (ERCP) or percutaneously
using image-guided transhepatic route. ERCP is successful in more than 90% of patients
who have normal upper gastrointestinal tract anatomy with no luminal obstruction.
However, in cases where ERCP is not possible due to various factors such as failed
cannulation, obstructed/altered upper gastrointestinal tract anatomy, distorted ampulla,
and large periampullary diverticulum, endoscopic ultrasound-guided biliary drainage
(EUS-BD) is being increasingly performed as an alternative to percutaneous transhepatic
BD (PTBD).[1 ],[2 ],[3 ],[4 ],[5 ],[6 ],[7 ]
There are three ways of performing EUS-BD: (i) rendezvous technique, in which guidewire
is passed through the papilla through a punctured intrahepatic or extrahepatic bile
duct and retrieved by duodenoscope for completion of the procedure through the transpapillary
route. (ii) Direct transmural stenting using transgastric hepaticogastrostomy or transduodenal
choledochoduodenostomy [ECD] without accessing the papilla. (iii) Antegrade transpapillary
stent placement following intrahepatic bile duct puncture.[1 ],[2 ],[3 ],[4 ],[5 ],[6 ],[7 ] The advantage of EUS-BD over percutaneous BD is that it maintains internal BD. However,
in contrast to ERCP and PTBD, it is associated with high complication rates of up
to 26% with bile leak being an important complication.[7 ] Furthermore, in the presence of extensively infiltrated duodenal mucosa, its safety
is not well established.
Here, we describe a challenging case of disseminated urinary bladder cancer that presented
with extensive duodenal as well as periduodenal infiltration leading on to gastrointestinal
bleed and severe pruritus along with obstructive jaundice and was successfully managed
with initial argon plasma coagulation (APC) of bleeding duodenal lesions followed
by ECD.
Case Report
A 58-year-old male, known case of transitional cell carcinoma of urinary bladder,
presented elsewhere with jaundice, pruritus, and melena. The patient was diagnosed
as transitional cell carcinoma of urinary bladder 32 months ago when he was evaluated
for hematuria. The patient underwent radical cystectomy and was apparently asymptomatic
till 4 weeks ago when he developed gradually progressive obstructive jaundice associated
with severe pruritus that was refractory to medical therapy. It was followed by melena
2 weeks later and gradually jaundice also deepened. Investigations revealed anemia
(hemoglobin of 5.2 g/dl) and conjugated hyperbilirubinemia (total of 18 mg% with conjugated
being 12.6 mg%). Upper gastrointestinal endoscopy revealed narrowing at junction of
first and second part of duodenum with extensive infiltration and oozing of fresh
blood from the site of narrowing. The gastroscope could not be negotiated beyond the
narrowing. Contrast-enhanced computed tomography revealed dilated biliary radicals
and common bile duct (CBD) with large lymph nodal mass obstructing the lower part
of bile duct [Figure 1 ]a and [Figure 1 ]b. Ultrasound-guided fine-needle aspiration from the lymph nodal mass revealed it
to be metastasis from bladder cancer. Patient was given multiple blood transfusions
and referred to our center.
Figure 1 : (a and b) Contrast.enhanced computed tomography: Dilated biliary radicals and common
bile duct (black arrow) with large lymph nodal mass (white arrow) obstructing the
lower part of bile duct
A repeat gastroscopy was performed, and it revealed infiltrated mucosa in both first
of duodenum as well as narrowed junction of first and second part of duodenum from
where fresh blood was oozing. APC of the bleeding duodenal lesions was done. Following
this, the bleeding stopped and the patient was subsequently taken up for ECD after
taking informed consent. EUS was done using a linear echoendoscope (GF-UCT 180, Olympus
Medical Systems Co., Tokyo, Japan) along with carbon dioxide insufflation and it revealed
a dilated CBD that was obstructed at the lower end with a large lymph nodal mass [Figure 2 ]. The duodenal wall at the site of narrowing was also thickened with loss of wall
stratification [Figure 2 ]. The CBD was punctured from the first part of duodenum, avoiding the infiltrated,
thickened duodenal wall using a 19G Flexible EUS needle (Expect, Boston Scientific,
Natick, Massachusetts) [Figure 3 ]a and [Figure 3 ]b. The cholangiogram revealed a dilated CBD with cutoff at the lower end [Figure 4 ]. Thereafter, a guidewire (VisiGlide; 0.025 inch; straight tip; Olympus Medical Systems
Co., Tokyo, Japan) was advanced to the hilar side of the CBD [Figure 5 ]. A fully covered self-expanding metallic stent (SEMS) (WallFlex; 10 mm diameter,
6 cm length, Boston Scientific, Natick, Massachusetts) was placed into the bile duct
after dilatation of the transmural tract over the guidewire [Figure 6 ]. The patient had an uneventful postprocedure course, and the pruritus subsided within
3 days of the procedure and jaundice started decreasing. The patient was thereafter
referred to oncology services for further management.
Figure 2 : Endoscopic ultrasound: dilated common bile duct with mass obstructing it. Thickened
duodenal wall also noted (*)
Figure 3 : (a and b) Endoscopic ultrasound.guided puncture of dilated bile duct
Figure 4 : Endoscopic ultrasound cholangiogram: Dilated common bile duct
Figure 5 : Guidewire negotiated toward the hilum
Figure 6 : Fully covered self.expanding metallic stent placed
On follow-up, patient became anicteric 14 days after the procedure and is jaundice
free after 2 months of follow-up. There has also been no recurrence of gastrointestinal
bleed.
Discussion
Since 2001, when Giovannini et al.[8 ] first reported new technique of EUS-guided bilioduodenal anastomosis, there has
been a gradual improvement in technique as well as accessories, and now EUS-BD is
being increasingly performed in cases where ERCP is not possible.[1 ],[2 ],[3 ],[4 ],[5 ],[6 ],[7 ] A systematic review of 42 studies with 1192 patients reported that the technical
success rate and functional success rate of EUS BD are high (94.71% and 91.66%, respectively).[9 ] However, it is also associated with high adverse events with frequency as high as
23.32%. This increased frequency of adverse events, namely, bleeding, bile leakage,
pneumoperitoneum, stent migration, cholangitis, and peritonitis limits its widespread
use.
Of the various options available for EUS BD, studies have shown varying results with
majority showing that both rendezvous as well as direct transluminal stenting techniques
as well as both transhepatic route and transduodenal route are equally safe and effective
and therefore the choice of route of access and technique used usually depends on
the endoscopist's preference.[9 ],[10 ],[11 ],[12 ],[13 ] The most concerning complication of transluminal EUS-BD is bile leakage and bleeding.
Bile leakage can be theoretically prevented by the use of FCSEMS that can seal the
gap between the stent and the walls of the fistula by expansion.[6 ]
Our case was more challenging as there was an increased risk of bleeding because of
extensive bleeding duodenal infiltration. We initially used APC to coagulate the bleeding
lesions and thereafter carefully chose the transmural site of puncture avoiding the
involved duodenal area and finally used fully covered SEMS that would have enhanced
hemostasis by tamponade effect.
Conclusion
EUS-guided choledochoduodenostomy using a fully covered SEMS is a safe and effective
treatment option for relieving malignant biliary obstruction even in the presence
of extensive bleeding duodenal infiltration that has been initially controlled by
APC.
Financial support and sponsorship
Nil.
