A 63-year-old man was admitted with obstructive jaundice. Computed
tomography (CT) scan showed a mass in the head of the pancreas. Endoscopic
retrograde cholangiopancreatography (ERCP) revealed a common bile duct
stricture, which was stented, and biliary brushings confirmed primary
pancreatic adenocarcinoma. As the tumor was unresectable, he underwent a double
bypass operation (i. e. hepaticojejunostomy and gastrojejunostomy). The
patient presented 2 months later with jaundice (bilirubin 300 mg/dL). CT
scan confirmed obstruction and dilatation of the hepaticojejunostomy loop due
to tumor invasion ([Fig. 1]).
Fig. 1 Computed tomography scan
reconstruction showing dilated hepaticojejunostomy loop (A), adjacent to the
stomach (B), with biliary stent in situ (C).
This was resulting in backflow obstruction of the bile duct, even
though the metal stent remained patent. The patient was unfit for further
surgery and percutaneous drainage was considered unsafe due to postsurgical
anatomy.
The dilated hepaticojejunostomy loop ([Fig. 2]) was identified at endoscopic ultrasound
(EUS) using a Pentax linear echo-endoscope (Pentax, Tokyo, Japan) and accessed
using a Cook cystotome (Wilson Cook, Winston-Salem, North Carolina, USA),
followed by ring diathermy.
Fig. 2 Endoscopic ultrasound
image of the dilated hepaticojejunostomy loop (A), with guide wire (B) in the
collection.
A 10-cm 4-Fr metal stent ([Figs. 3] and
[4]) was placed without any complications, and 2 days
later the bilirubin had dropped to 100 mg/dL.
Fig. 3 Endoscopic ultrasound
image of the metal stent (A) in the collection after deployment.
Fig. 4 Endoscopic image of the
metal stent in the fundus.
EUS is widely used in the drainage of pancreatic pseudocysts
[1]. Piraka et al. have demonstrated that it is
technically feasible to drain virtually any fluid collection as long as it is
adjacent to the gastrointestinal lumen and within reach of the echoendoscope
[2]. EUS has been used to drain postoperative and
peripancreatic fluid collections [3]
[4]. EUS-guided drainage can offer all the benefits of
radiologically guided percutaneous drainage with the additional advantage of
avoidance of transcutaneous infection [5]. A short
distance (< 2 cm) between the fluid collection and viscus,
lack of ascites, and maturity of the fluid cavity all decrease risk of leakage
at the puncture site [2].
Our case demonstrates the use of EUS in relieving biliary
obstruction by drainage of an obstructed hepaticojejunostomy loop with
transgastric gastroenterostomy.
Endoscopy_UCTN_Code_TTT_1AS_2AG
