Novel approach for unresectable pancreatic mass with duodenal obstruction

Alberto Larghi, MD, PhD, from the Digestive Endoscopy Unit, Catholic University, in Rome, Italy discusses this VideoGIE case “Single-session EUS-guided FNA and biliary drainage with use of a biflanged lumen apposing stent on an electrocautery enhanced delivery system: one-stop shop for unresectable pancreatic mass with duodenal obstruction.”

The video case describes the possibility of performing, in a patient with both duodenal and biliary obstruction from an unresectable pancreatic head tumor, EUS-FNA for tissue diagnosis and EUS-guided biliary drainage using a novel lumen apposing fully covered self-expandable metal stent (LA-SEMS) mounted on an electrocautery-enhanced delivery system (Hot AXIOS™, Xlumena Inc., Mountain View, CA, USA) in one single procedure. The day after, a duodenal stent to palliate the GI tract obstruction was also placed. The patient died 6 months later without need for any stent revision. Endoscopic palliation of unresectable pancreatic cancer with both duodenal and common bile duct (CBD) obstruction is cumbersome, with successful biliary drainage achieved in only 30% of the cases. In most patients, percutaneous biliary drainage is necessary. The possibility in such patients of performing tissue diagnosis and biliary drainage in the same session is very appealing. This is made possible by the availability of rapid on-site cytopathology evaluation and the use of a newly developed LA-SEMS, specifically designed to be placed under EUS guidance. EUS-guided biliary drainage is rapidly evolving and is becoming a valid alternative to percutaneous biliary drainage, with the advantage from the patient’s perspective to avoid the discomfort, local pain and cosmetic disfigurement associated with the percutaneous catheter. Moreover, the subsequently placed duodenal stent did not interfere with the biliary stent and both remained patent for 6 months.

Figure 1. EUS-guided deployment of the distal flange of the stent inside the common bile duct (arrow).

From this experience others endoscopists can learn that in patients with unresectable pancreatic head cancer with CBD obstruction and unreachable papilla, there is an effective alternative way to first palliate the jaundice and reach a definitive diagnosis in one single endoscopic procedure all done under EUS guidance. This can be then followed by endoscopic relief of the GI tract obstruction, in the same session, but also afterwards as in our case. For these patients with short life expectancy, the possibility of reducing the number of procedures and increasing the comfort avoiding any external drainage is very important.

In the future, if the stent stays patent for long time with a low need for re-intervention, the one-stop shop procedure presented has the potential to be applied to all patients with unresectable distal common bile duct obstruction.

Find more VideoGIE cases online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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