Published online Nov 16, 2020. doi: 10.4253/wjge.v12.i11.488
Peer-review started: June 19, 2020
First decision: August 22, 2020
Revised: September 15, 2020
Accepted: October 9, 2020
Article in press: October 9, 2020
Published online: November 16, 2020
Processing time: 149 Days and 22.9 Hours
Head pancreatic cancers often present with clinical challenges requiring biliary drainage for chemotherapy or palliative scope. If usual endoscopic modalities fail or if percutaneous approach is not feasible, endoscopic ultrasound (EUS) guided biliary drainage can be considered. Here we describe and discuss an interesting clinical case in which EUS-guided gallbladder drainage (EUS-GBD) was chosen to treat acute severe cholangitis in a patient with advanced pancreatic cancer.
An 84-year-old female with a previous EUS-biopsy proven diagnosis of head pancreatic cancer presented with clinical signs of acute cholangitis. In September 2018 she had positioned a biliary and duodenal stent to relieve jaundice and an initial duodenal substenosis. In the emergency ward, an abdominal computed tomography scan showed proximal biliary stent occlusion due to neoplastic progression, but endoscopic retrograde cholangiopancreatography was impossible because of worsening duodenal stenosis and the absence of a chance to reach the Vater’s papilla area. EUS-guided choledocoduodenostomy was not technically feasible but because the cystic duct was free of neoplastic infiltration, an EUS-GBD using an Axios™ stent was successfully performed. The patient started to feed after 48 h and was discharged 1 wk later. No other hospitalizations due to cholangitis or symptoms of Axios™ stent occlusion/dysfunction were observed up until her death 6 mo later due to underlying disease.
This case demonstrated how different EUS therapeutic approaches could have a key role to treat critical and seemingly unsolvable situations and that they could play a more fundamental role in the next future.
Core Tip: The present case explored the feasibility, safety and efficacy of an endoscopic ultrasound-guided gallbladder drainage to decompress the biliary tree and treat severe cholangitis in a patient with advanced pancreatic cancer. Endoscopic ultrasound-guided gallbladder drainage could be effective to drain the biliary tree if the cystic duct is free from neoplastic tissue. Using the new lumen-apposing self-expandable metallic stent, the procedure could be technically and clinically feasible, safe and an effective alternative to conventional endoscopic retrograde cholangiopancreatography or percutaneous drainage.