Endoscopic biliary drainage for distal bile duct obstruction due to pancreatic cancer

Abstract

Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

Keywords: Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound-guided biliary drainage; Hepatobiliary diseases; Pancreatic neoplasms.

Fig. 1.

A case of repeated reflux cholangitis after fully covered self-expandable metal stent placement and duodenal stenting for distal biliary obstruction and duodenal obstruction. (A) Duckbill biliary stent (Kawasumi Laboratories Inc.): The stent has two additional meshes at the distal end to regulate the opening of the valve; the valve is normally closed to prevent reflux of duodenal contents into the bile duct, but opens to allow bile to flow out when the bile duct pressure increases. (B) Radiographic image: Duodenography showing reflux of the contrast medium into the bile duct. (C) Radiographic image: After placement of the Duckbill biliary stent, duodenography shows no reflux of the contrast medium into the bile duct.

Fig. 2.

Endoscopic ultrasound-guided hepaticogastrostomy using the Spring Stopper Stent (Taewoong Medical). (A) Partially braided self-expandable metal stent with a spring-type stopper on the luminal side (Niti-S Spring Stopper Stent; Taewoong Medical). (B) Radiographic image: fistula formation using a Spring Stopper Stent between the intrahepatic bile duct and stomach. (C) Endoscopic view of the Spring Stopper Stent.

Fig. 3.

Endoscopic ultrasound-guided hepaticogastrostomy using the Hook Stent (ZEON Medical). (A) Partially laser-cut self-expandable metal stent with a hook structure on the luminal side (Hook Stent). (B) A thin delivery system for a 0.025-inch guidewire with a 7.2-Fr shaft. (C) Endoscopic view of the Hook Stent.