Combined endoscopic retrograde cholangiopancreatography- and endoscopic ultrasound-guided palliative biliary drainage in surgically altered anatomy.
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BACKGROUND AND AIMS: Long-term endoscopic management of malignant hilar biliary obstruction can be challenging, especially in cases with surgically altered anatomy. METHODS: A 37-year-old woman with newly diagnosed metastatic gastric adenocarcinoma status postneoadjuvant chemotherapy followed by a subtotal gastrectomy with Roux-en-Y reconstruction developed malignant hilar biliary obstruction. She underwent an ERCP via the use of a pediatric colonoscope, with sampling of the hilar stricture and stenting with a 7F × 12-cm plastic stent in the right hepatic duct. Pathology confirmed metastatic adenocarcinoma. ERCP with scheduled biliary stent exchange was recommended; however, the patient requested a long-term endoscopic solution to obviate routine stent exchange and avoid percutaneous drainage. We performed a combined procedure with a pediatric colonoscope-assisted ERCP to place an uncovered metal stent in the right hepatic ductal system and an EUS-guided hepaticogastrostomy in the same endoscopic session to drain the left hepatic ductal system separately. RESULTS: When seen at follow-up 8 months later, the patient was doing well clinically, with unremarkable liver chemistries and follow-up imaging demonstrating appropriate positioning of stents. CONCLUSIONS: Combined ERCP and EUS-guided biliary drainage techniques can provide an effective alternative to ERCP alone or percutaneous biliary drainage for palliation of malignant hilar biliary obstruction.