A Case of Malignant Biliary Obstruction with Severe Obesity Successfully Treated by Endoscopic Ultrasonography-Guided Biliary Drainage

Abstract

Here, we present a case of malignant biliary tract obstruction with severe obesity, which was successfully treated by endoscopic ultrasonography-guided biliary drainage (EUS-BD). A female patient in her sixties who had been undergoing chemotherapy for unresectable pancreatic head cancer was admitted to our institution for obstructive jaundice. She had diabetes mellitus, and her body mass index was 35.1 kg/m². Initially, endoscopic retrograde cholangiopancreatography (ERCP) was performed, but bile duct cannulation was unsuccessful. Percutaneous transhepatic biliary drainage (PTBD) from the left hepatic biliary tree also failed. Although a second PTBD attempt from the right hepatic lobe was accomplished, biliary tract bleeding followed, and the catheter was dislodged. Consequently, EUS-BD (choledochoduodenostomy), followed by direct metallic stent placement, was performed as a third drainage method. Her postprocedural course was uneventful. Following discharge, she spent the rest of her life at home without recurrent jaundice or readmission. In cases of severe obesity, we consider EUS-BD, rather than PTBD, as the second drainage method of choice for distal malignant biliary obstruction when ERCP fails.

Figure 1

MRCP showed biliary obstruction in the lower portion and dilatation of the upstream bile duct.

Figure 2

A hypoenhanced, irregular-shaped mass in the pancreatic head (red circle), as visualized by CT. The distance from the skin to the liver surface exceeded 4 cm (red arrows).

Figure 3

PTBD procedures. (a) Repeated PTBD by a right-sided intercostal approach was successful. (b), (c) After 2 days, the PTBD catheter was dislodged to the caudate lobe. Replacement of the catheter was unsuccessful.

Figure 4

EUS-BD procedures. (a) The extrahepatic bile duct was visualized from the duodenal bulb using a curved linear array echoendoscope and punctured using a 19-G fine-aspiration needle. (b) The biliary tract was opacified with contrast medium. (c) A fully covered metallic stent was deployed through the choledochoduodenal fistula. Red arrows show the waist of the stent induced by the choledochal and duodenal walls. (d) Endoscopic view of the deployed stent observed from the pylorus.