Combined ERCP and US-guided palliative biliary drainage in altered anatomy. We have no disclosures. Our patient is a 37-year-old female with no significant past medical history who initially presented to the emergency room with abdominal pain. She was found to have a 10 by 15 centimeter adnexal mass thought to be of ovarian origin on CT scan. She underwent an expiratory laparotomy with removal of the adnexal mass, an extensive dissection including left and right fallopian tubes, and a salpingo-ophorectomy. Pathology from this mass showed metastatic adenocarcinoma of GI origin. Hence, she underwent an EGD which showed diffused thickening of the lesser curvature and antrum, biopsies of which confirmed poorly differentiated adenocarcinoma. She also underwent an EUS that showed wall thickening of layer 3 and 4 corresponding with findings on EGD. After discussion at a multidisciplinary tumor board, the patient was recommended neoadjuvant chemotherapy with Hypec therapy. Following this, she underwent a robotic-assisted subtotal gastrectomy with ruin by reconstruction and extensive intra-abdominal debulking. However, on routine follow-up six months later, unfortunately, she was noted to have a soft tissue mass near the hepatic hilum causing intra-hepatic biliary ductal dilation. This can be seen on the CT scan. For management of hilar obstruction and for obtaining a tissue diagnosis, patient underwent a pediatric colonoscope-assisted ERCP given her Roux-en-Y anatomy. In the top left, you see the configuration of the pediatric colonoscope required to achieve a cannulation position which can be seen in the picture on the bottom left. The cholangiogram showed a complex hilar structure which was sampled, then balloon dilated to 6 mm, following which a 7-fringe by 12-centimeter plastic stent was placed. However, because of logistical and financial difficulties, patient was unwilling to commit to serial ERCP with stenting despite the fact that pathology confirmed metastatic adenocarcinoma. She requested a long-term solution. We opted for a combined approach to draining her right and left hepatic system. The first step was drainage of the right hepatic system. Using a pediatric colonoscope, the previously placed stent was removed and cholangiogram showed a complex hilar structure. The structured bile duct were dilated with a balloon dilator and a 10-millimeter by 6-centimeter uncovered metal stent was placed into the right hepatic duct. We then moved on to management of her left hepatic system. The pediatric scope was removed in exchange for an echoendoscope. Using the echoendoscope, a segment to left intrahepatic bile duct was identified and duct was confirmed using contrast injection. Switching to fluoroscopic view, we see filling of the left hepatic duct system and a complex structure in the left main hepatic duct. The hepaticogastrostomy tract was created and then dilated to 4-millimeter with a balloon dilator. Following this, a 10-millimeter by 8-centimeter fully covered self-expanding metal stent was deployed across this tract. A 7-inch by 7-centimeter double pigtail plastic stent was placed coaxially through this self-expandable metal stent. In summary, we successfully achieved palliative belly re-drainage for this patient with malignant hiler obstruction and Roux-en-Y anatomy with the use of a combined ERCP and EUS approach. For the right hepatic system, we placed an uncovered metal stent with ERCP. For the left hepatic system, we performed a hepatico-jejunostomy with placement of a fully covered stent and coaxial plastic stent. The patient was seen in follow-up approximately eight months later and was clinically doing well. Her liver enzymes were within normal limits. This CT shows stable stent positions with the green arrow pointing to the hepatico-jejunostomy and the yellow arrow to the uncovered right hepatic duct stent. Palliative belly re-drainage and malignant hiler obstruction can be challenging. Combined approaches are often required to obtain more than 50% sectoral drainage, as is recommended by most guidelines. There are various options here, including use of ERCP with bilateral stenting, ERCP with percutaneous drainage, and ERCP with EUS guided drainage. This can be in the form of an EUS guided hepatico-gastrostomy with right-sided stenting or an EUS guided hepatico-jejunostomy with left-sided stenting. This is especially useful in cases with altered anatomy, where use of forward-viewing instruments may make bilateral stenting with ERCP challenging. Using a combined ERCP and EUS approach can provide effective drainage internally, potentially leading to improved quality of life and survival. In conclusion, in select patients, a combined ERCP and EUS guided belly re-drainage approach provides an effective internal alternative to ERCP and percutaneous drainage for long-term management of malignant hiler strictures.

ERCP

EUS-guided procedure

palliative biliary drainage

metal stent

hepatico-gastrostomy