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Korean J Pancreas Biliary Tract. 2023;28(1):19-22

Publication date (electronic) : 2023 January 31

doi : https://doi.org/10.15279/kpba.2023.28.1.19

Young Rong Kim^1,*, Chi Hyuk Oh^2,*, Min Jae Yang^,3

¹Department of Infectious Diseases, Ajou University School of Medicine, Suwon, Korea

²Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea

³Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea

김영롱^1,*, 오치혁^2,*, 양민재^,3

¹아주대학교 의과대학 감염내과

²경희대학교 의과대학 소화기내과

³아주대학교 의과대학 소화기내과

Corresponding author : Min Jae Yang Department of Gastroenterology, Ajou University School of Medicine, 164 WorldCup-ro, Yeongtonggu, Suwon 16499, Korea Tel. +82-31-219-7821 Fax. +82-31-219-7820 E-mail; creator1999@hanmail.net

*Young Rong Kim and Chi Hyuk Oh contributed equally to this work and share the first authorship.

Received 2022 November 15; Accepted 2023 January 25.

Abstract

Trans Abstract

INTRODUCTION

Gallbladder cancer is the most common cause of hilar biliary obstruction [1]; however, it rarely causes combined biliary, duodenal, and colon triple obstruction [2,3]. In patients with terminal cancer, unable to tolerate chemotherapy, endoscopic enteral and biliary stenting can be major palliative modalities to not only guarantee enteral nutrition but also to improve the quality of life of the patient by maintaining internal biliary drainage [4]. In this case, seven metal stents were implanted one by one using endoscopic and endosonographic methods to palliate complex gastrointestinal and biliary obstruction.

CASE

A 61-year-old male underwent laparoscopic cholecystectomy for gallbladder cancer and received palliative chemotherapy for recurrent gallbladder bed tumor 4 and 2 years prior, respectively. The treatment was discontinued because it had no impact, and the patient had developed an intolerance to it. Plastic stents were placed, at another hospital, for tumor-induced hilar biliary obstruction (Fig. 1A). He presented at our emergency department with vomiting that had worsened progressively over 5 days. An uncovered duodenal self-expandable metal stent (SEMS) was placed across a malignant stricture at the superior duodenal angle (Fig. 1B, C, F). He was readmitted 2 months later with abdominal cramps and was unable to pass feces (Fig. 1D). We then inserted an uncovered SEMS across a malignant stricture at the hepatic flexure of the colon (Fig. 1E, F). The patient returned to the emergency department 2 months later with jaundice. We performed endoscopic retrograde cholangiopancreatography (ERCP) for endoscopic reintervention, however selective cannulation of the segment 2 or 3 intrahepatic bile duct (IHD) was unsuccessful. We, therefore, placed two uncovered SEMSs across segment 4 and the right anterior IHDs, using the stent-in-stent technique (Fig. 2A, B). Unfortunately, jaundice persisted. We performed endoscopic ultrasound-guided hepaticogastrostomy via segment 3 IHD using a partially covered SEMS (Fig. 2C, D), which led to clinical improvement. The patient returned with recurrent jaundice 2 months later. We successfully performed selective cannulation of segment 2 IHD with uncovered metal stent placement through ERCP (Fig. 2E). Subsequently, we placed a fully covered SEMS in the indwelling hepaticogastrostomy stent (Fig. 2F). Three months later, the patient died of hepatic infarction secondary to tumor progression without placement of an external drainage tube.

Fig. 1.

(A) Abdominal computed tomography scan showing recurrent gallbladder bed tumor-induced hilar obstruction. (B) Endoscopic image showing food in the stomach despite a long period of fasting. (C) An uncovered duodenal stent is placed across the stricture at the superior duodenal angle. (D) Abdominal computed tomography scan showing marked dilatation of the ascending colon secondary to tumor invasion, which suggests colonic obstruction. (E) An uncovered metal stent is inserted across the stricture at the hepatic flexure. (F) Abdominal computed tomography scan showing the duodenal and colonic stents.

Fig. 2.

(A) Image showing two uncovered metal stents placed at the segment 4 and right anterior intrahepatic bile ducts. (B) The 2nd biliary stent is placed across the papilla to localize the biliary orifice. (C, D) Images showing the endoscopic ultrasound-guided hepaticogastrostomy using a partially covered metal stent for internal drainage. (E) Image showing successful selective cannulation of the segment 2 intrahepatic bile duct with metal stent placement. (F) Image showing placement of an additional fully covered metal stent in the indwelling hepaticogastrostomy stent.

DISCUSSION

Patients with hepatobiliary and pancreatic cancer or postoperative relapse of cancer often present with combined biliary and intestinal obstruction [2,3]. In this case, the quality of life for a patient with recurrent gallbladder cancer with combined duodenal, colonic, and biliary obstruction was improved by endoscopic and endosonographic palliation, despite its technical difficulty and complexity. Seven metal stents were implanted one by one using only endoscopic methods. Successful stent-in-stent placement and endoscopic ultrasound-guided stenting after failed ERCP improved the patient’s quality of life to the extent that there was no need for any external drainage. To the best of our knowledge, no report in the literature describes recurrent gallbladder cancer complicated by hilar biliary, duodenal, and colonic triple obstruction, with palliation provided exclusively with internal endoscopic stenting.

Traditionally, a surgical bypass has been applied to relieve combined biliary and intestinal obstruction, but due to its substantial morbidity and mortality, non-operative measures such as endoscopic enteral stenting and percutaneous transhepatic biliary intervention have been used to provide effective palliation [2,3]. Currently, the development of endoscopic techniques and the invention of new metallic stents have enabled endoscopists to perform endoscopic stenting in complex cases.

However, many patients have had to experience permanent external percutaneous transhepatic biliary drainage before death, because prior complex biliary and enteral stenting precluded successful ERCP for biliary stent revision. Maintaining external drainage-tube-related discomfort and pain compromises quality of life in the final months of terminal cancer patients. Recently, endoscopic ultrasound-guided biliary drainage has gained popularity as an alternative to percutaneous transhepatic biliary drainage for the treatment of malignant biliary obstruction [5]. It enables internal drainage and changes existing biliary flow to the new transmural route, bypassing the transpapillary route where indwelling biliary and enteral stents are packed in a tight space. Therefore, collaborative applications of endoscopic, duodenoscopic, endoscopic ultrasonography-guided stenting can contribute significantly to an improved prognosis for patients who have suffered from complex gastrointestinal and biliary obstructions related to hepatobiliary and pancreatic cancer.

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