Endoscopic palliation of advanced pancreatic carcinomas with biliary and gastric outlet
obstruction involves the placement of self-expanding metal stents (SEMS) within the
biliary tree and the duodenum [1]
[2]
[3]
[4]
[5]. Biliary stenting following duodenal stenting across the papilla usually requires
a percutaneous transhepatic approach [1]
[4]
[5]. We report a case in which a biliary SEMS was placed endoscopically through the
mesh wall of a previously inserted duodenal SEMS.
A 64-year-old woman with an unresectable carcinoma of the pancreatic head was admitted
because of progressive jaundice and gastric outlet obstruction. Some 2 months previously
a plastic endoprosthesis had been placed into the common bile duct (CBD) after sphincterotomy
at endoscopic retrograde cholangiopancreaticography (ERCP). A repeat ERCP now revealed
a 30 mm long high-grade stenosis of the second part of the duodenum, which could not
be passed by the duodenoscope even after balloon dilation. The plastic endoprosthesis
was removed by snare under fluoroscopic guidance and a SEMS was placed into the duodenal
stenosis (Enteral Wallstent, uncoated, 22 mm, 60 mm; Microvasive Corporation, Natick,
Massachusetts, USA). At 2 days later the duodenal SEMS had expanded, and at a further
ERCP, cannulation of the CBD was possible and showed a high-grade stenosis (Figure
[1]). A loop of the mesh wall of the duodenal stent in the region of the papilla Vateri
was enlarged by balloon dilation (8 mm) (Figure [2]), and a biliary SEMS was successfully placed through this loop into the CBD (Biliary
Wallstent, uncoated, 10 mm, 42 mm; Microvasive Corporation) (Figure [3]). The jaundice disappeared and the patient was able to eat soft food.
Figure 1 The common bile duct was cannulated and visualized by pushing the catheter through
the mesh wall of the duodenal stent. A dilated bile duct above a distal high-grade
stenosis 18 mm in length was seen. The sphincterotomy had been performed previously.
Figure 2 The stenosis of the common bile duct and one loop of the mesh wall of the duodenal
stent, in the region of the papilla Vateri, were expanded by balloon dilation. The
balloon was pushed through the mesh wall of the duodenal stent.
Figure 3 Radiological view after successful placement of the biliary self-expanding metal stent
through the mesh wall of the duodenal stent.
This case report shows that endoscopic positioning of a biliary SEMS can be successful
even after placement of a duodenal one, if sphincterotomy has been performed previously.
However, passage of the biliary stent through the side meshes of a SEMS can be difficult
and may not work in all cases; and it is therefore not a standard procedure.
