Post written by Ahmed Altonbary, MD, FRCP, from Mansoura Specialized Medical Hospital, Mansoura University, Mansoura, Egypt.
We describe a case of unresectable pancreatic cancer with extrahepatic biliary obstruction and duodenal invasion that was successfully treated with a variant of EUS-guided biliary drainage by performing EUS-guided choledochoantrostomy (EUS-CAS).
EUS-guided choledochoduodenostomy (EUS-CDS) is commonly performed for biliary decompression after failed ERCP. However, EUS-CDS is sometimes infeasible in cases of duodenal bulb invasion because of difficulty in advancing the echoendoscope and limited space to deploy the metal stent.
EUS-CAS is a potential alternative for biliary decompression in patients with malignant distal biliary obstruction and duodenal bulb invasion. The technical advantages of this technique over EUS-guided hepaticogastrostomy are the more stable position of the echoendoscope and physiological biliary drainage by providing normal anterograde bile flow.
In conclusion, EUS-CAS appears to be a safe alternative for biliary decompression in patients with malignant distal biliary obstruction and duodenal bulb invasion.
EUS showing dilated common bile duct (29 mm) and dilated cystic duct.
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the problem of choledoco-antrostomy is similar to gallbladder drainage into the stomach and the big risk is related to gastric peristalsis that is extremely strong and sustained whilst duodenal bulb is fixed. So in the bulb there is no risk for dislogment or buried sindrome while in the antrum it is more probable and frequent.