Simultaneous Duodenal Metal Stent Placement and EUS-Guided Choledochoduodenostomy for Unresectable Pancreatic Cancer

Abstract

Patients with pancreatic cancer frequently suffer from both biliary and duodenal obstruction. For such patients, both biliary and duodenal self-expandable metal stent placement is necessary to palliate their symptoms, but it was difficult to cross two metal stents. Recently, endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) was reported to be effective for patients with an inaccessible papilla. We report two cases of pancreatic cancer with both biliary and duodenal obstructions treated successfully with simultaneous duodenal metal stent placement and EUS-CDS. The first case was a 74-year-old man with pancreatic cancer. Duodenoscopy revealed that papilla had been invaded with tumor and duodenography showed severe stenosis in the horizontal portion. After a duodenal uncovered metal stent was placed across the duodenal stricture, EUS-CDS was performed. The second case was a 63-year-old man who previously had a covered metal stent placed for malignant biliary obstruction. After removing the previously placed metal stent, EUS-CDS was performed. Then, a duodenal covered metal stent was placed across the duodenal stenosis. Both patients could tolerate a regular diet and did not suffer from stent occlusion. EUS-CDS combined with duodenal metal stent placement may be an ideal treatment strategy in patients with pancreatic cancer with both duodenal and biliary malignant obstruction.

Keywords: Duodenal stent; Endoscopic ultrasonography-guided choledochoduodenostomy; Malignant biliary obstruction.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1

Duodenoscopy showing duodenal invasion and obstruction at the anal side of the papilla (arrow).

Fig. 2

Endoscopic images showing (A) an uncovered duodenal metal stent and (B) a transmural biliary stent at the duodenal bulb, and (C) a fluoroscopic image showing the choledochoduodenostomy and duodenal stent.

Fig. 3

Duodenography showing severe stenosis on the oral side of the papilla (arrow).

Fig. 4

Endoscopic images showing (A) a transmural biliary stent at the bulb and (B) a covered duodenal metal stent, and (C) a fluoroscopic image showing the choledochoduodenostomy and duodenal stent.