The patient is a 66 year old man with history of T3N1 pancreatic adenocarcinoma status post-whipple resection three years prior and adjuvant chemotherapy. He subsequently developed local recurrence in the pancreatic tail and liver metastases. Eight months prior to presentation, he was admitted with afferent limb obstruction and underwent successful EUS guided jejunal jejunostomy using a 15 millimeter luminoposal metal stent. One week prior to presentation, he was found to have worsening liver tests from a baseline of normal. He was subsequently evaluated with an MRCP. The MRCP showed marked intrahepatic biliary ductal dilatation with obstruction of the hepatic jejunal anastomosis extending along the right and left hepatic duct confluence. The findings were suggestive of separate obstructions of the left and right hepatic ducts. Options for biliary drainage were discussed with the patient including ERC via the pancreatic biliary limb, EUS assisted biliary drainage, and percutaneous transhepatic biliary drainage. The anticipated need for bilateral drainage and the possible need for percutaneous drainage, especially of the right hepatic duct in case retrograde drainage was not successful, was discussed. After discussing the risks and benefits of each approach, the patient elected for endoscopic retrograde drainage with EUS guided drainage as a backup option. An upper endoscope was advanced to the jejunal jejunal anastomosis where the luminoposal metal stent into the afferent limb was visualized. The stent was removed using a rat tube forcep. The afferent limb was explored through the fistulas tract. An area of infiltrative mass in the expected area of the hepatic jejunal anastomosis was visualized. Cannulation of this area with both the endoscope and ERCP scope was not successful. We then proceeded with EUS guided biliary drainage. The therapeutic linear echo endoscope was used to evaluate the liver from the stomach and jejunum. The left lobe intrahepatic ducts were dilated. The left lobe biliary tree was accessed using a 19 gauge needle. Contrast was injected. A cholangiogram was obtained. There was marked dilation of the entire left intrahepatic biliary tree. A large volume of contrast was injected to assess the right hepatic duct. However, there was no filling of the right hepatic ducts. Under fluoroscopic guidance, a 0.025 inch guide wire was advanced into the left hepatic duct and advanced across the hepatic jejunal anastomosis. The 19 gauge needle was removed. The left hepatic duct was then accessed using a 5 French tapered cannula. To dilate the tract. Further injection of contrast revealed a 3 centimeter long stricture of the left hepatic duct. The stricture was treated with a 10 French by 6 centimeter laser cut uncovered metal biliary stent. Following intragrade stent deployment, the duodenoscope was inserted and used to identify the trans-anastomotic left hepatic duct stent. The stent was in good position. Cannulation of the right hepatic duct through the stent was not successful despite multiple attempts. We then decided to proceed with EUS guided rendezvous to drain the right hepatic duct. The linear echoendoscope was reinserted and advanced into the jejunum to visualize the right lobe of the liver. Peripheral branches of the right lobe were identified. A 19 gauge needle was used to access a peripheral branch of the right biliary tree. Contrast was injected to confirm position in the biliary system. A 0.025 inch wire was successfully advanced into the main right hepatic duct. The wire was then advanced through the mesh of the previously placed left hepatic duct stent into the jejunum. The EUS scope was removed while leaving the wire in place for rendezvous. The duodenoscope was advanced to the jejunum. The wire was identified and grasped with a standard snare. The scope was removed and the wire was pulled through the patient's mouth in order to floss the wire. The rendezvous wire can be visualized through the metal biliary stent. While using the rendezvous wire as a guide, a bi-directional cannula and an angled 0.025 inch guide wire were used to access the right hepatic duct through the mesh of the left hepatic duct stent. Contrast injection showed marked dilation of the right hepatic duct with an abrupt cutoff immediately proximal to the bifurcation. The stricture and mesh of the left hepatic duct stent were dilated using a 4 mm dilation balloon. A 10 mm by 6 cm uncovered laser-cut biliary metal stent was then deployed in the right hepatic duct across the mesh of the left hepatic duct in a Y configuration. Pneumobilia can now be seen in the right hepatic lobe. The right hepatic duct stent was then dilated using a 6 mm balloon. There was good drainage of bile. The rendezvous wire was then removed and the right hepatic duct stent was then dilated using a 6 mm dilation balloon. The right hepatic duct stent was then dilated using a 6 mm balloon. The rendezvous wire was subsequently removed. The patient was admitted to the hospital for observation post-procedure. There was no evidence of a procedure-related adverse event and the patient was discharged the following day with a 7-day course of antibiotics. Prior to discharge, his bilirubin had improved from 10 to 7.8. Last follow-up was 3 months post-procedure, at which point his total bilirubin was normal. He is engaged in home-based palliative care in addition to receiving palliative radiation therapy. Retrograde biliary drainage via the trans-papillary route or trans-anastomotic route in patients with altered anatomy is a standard approach. In patients with inability to gain retrograde access either due to complete obstruction or inability to locate the anastomosis, options include percutaneous drainage or EUS-guided entrograde or rendezvous biliary drainage. EUS approaches typically involve access via the left hepatic duct. There are a few case reports of right hepatic duct access. In this case, there was complete obstruction of both the right and left hepatic ducts, which further complicated management. If endoscopic drainage was not successful, two percutaneous drains would be required for complete drainage. We showed that internal drainage may be possible with a single-session simultaneous entrograde and retrograde EUS-guided approach and placement of biliary metal stents in a Y-configuration. In conclusion, complete internal drainage of malignant biliary obstruction may be feasible in patients with altered anatomy with a combination of entrograde and rendezvous approaches in a single session.

pancreatic adenocarcinoma

liver metastases

biliary obstruction

endoscopic retrograde drainage

EUS-guided drainage