Endoscopic metal stenting of common bile duct for unresectable pancreatic cancer

Obstructive jaundice occurs in many patients with unresectable pancreatic cancer. Endoscopic therapy is the best palliative option for inoperable pancreatic cancers, either for the treatment of a potential duodenal stenosis or, in the majority of cases, for the treatment of the associated jaundice. Metal stents are preferable to plastic stents in patients who have a life expectancy of more than 3 months. The obstruction of the common bile duct is due to cancer of the head of the pancreas that compresses the biliary tree. However, in a few cases, the mucosa of the ampulla is also involved with malignancy from the adjacent pancreas. We present the case of two patients with unresectable pancreatic cancer, obstructive jaundice and pruritus, in which the drainage of the common bile duct was achieved with an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with insertion of an uncovered metal stent (Wallflex® type) with subsequent relief of the jaundice. Endoscopic drainage of the common bile duct for obstructive jaundice for unresectable pancreatic cancer is the preferred palliative approach in this type of patient.

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Endoscopic metal stenting of common bile duct for unresectable pancreatic cancer

Authors

Gf Donatelli, M Gualtierotti, D Coumaros

Abstract

Obstructive jaundice occurs in many patients with unresectable pancreatic cancer.
Endoscopic therapy is the best palliative option for inoperable pancreatic cancers, either for the treatment of a potential duodenal stenosis or, in the majority of cases, for the treatment of the associated jaundice.
Metal stents are preferable to plastic stents in patients who have a life expectancy of more than 3 months. The obstruction of the common bile duct is due to cancer of the head of the pancreas that compresses the biliary tree. However, in a few cases, the mucosa of the ampulla is also involved with malignancy from the adjacent pancreas.
We present the case of two patients with unresectable pancreatic cancer, obstructive jaundice and pruritus, in which the drainage of the common bile duct was achieved with an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with insertion of an uncovered metal stent (Wallflex® type) with subsequent relief of the jaundice.
Endoscopic drainage of the common bile duct for obstructive jaundice for unresectable pancreatic cancer is the preferred palliative approach in this type of patient.

Classification

clinical cases

Keywords

Endoscopic metal stenting, common bile duct, unresectable pancreatic cancer, CBD

Media type

Surgical video

Duration

04'16''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2665.htm

Endoscopic metal stenting of common bile duct for unresectable pancreatic cancer

1. First case presentation 00'08''

This is a case of an 89-year-old woman who was referred to our unit following three weeks of weight loss and a jaundice that had been lasting for the last seven days. An abdominal ultrasound examination showed a dilatation of both the intra- and extra-hepatic bile ducts, but the pancreas could not be seen due to the patient’s important body mass index. A MRI scan was performed: it revealed a tumoral lesion of 3cm in diameter at the level of the head of the pancreas, resulting in extrinsic compression of the middle part of the common bile duct and dilatation of the upper extra-hepatic and intra-hepatic bile ducts, both left and right. On the second day of her admission, an Endoscopic Retrograde Cholangio-Pancreatography was performed. The papilla had a normal aspect.

2. Common bile duct catheterization 00'52''

The catheterization was accomplished with the aid of a standard rapid exchange papillotome and a straight guidewire.

3. Upper common bile duct dilatation 00'58''

After leaving the guidewire in place using fluoroscopy and contrast injection, a 15mm dilatation of the upper common bile duct was demonstrated above a 2cm long stenosis at the mid-part of the common bile duct.

4. Sphincterotomy 01'12''

A small sphincterotomy was then performed using an Endocut current. The sphincterotome was withdrawn afterwards, leaving the guidewire in place.

5. Metal stent insertion 01'31''

Considering the good general state of the patient, we decided to deliver a metal stent: we chose a 6cm long uncovered Wallflex® metal stent with a diameter of 10 French. The stent was inserted over the guidewire, and under fluoroscopic control, it was advanced above the stricture where it was partially deployed and centered across the stricture before its full expansion. During stent delivery, particular attention was paid to avoid the stent’s sliding in the common bile duct. In the meantime, we carefully proceeded to the release of the stent at least 1cm out of the papilla. After the stent was placed, the good drainage of the common bile duct was evidenced by the flow of black-colored bile through the papilla. The serum level of bilirubin had markedly decreased the day after. Two days after, the patient was discharged and one week later, the liver function tests were within the normal range.

6. Second case presentation 02'23''

The second case is that of a 71-year-old patient who was admitted to our department for jaundice and a deterioration in his general health conditions. A CT-scan suggested the diagnosis of a cystadenocarcinoma of the head of the pancreas, with a 20mm dilatation of the common bile duct and a dilatation of the intra-hepatic bile ducts. An ERCP was then performed in order to place a stent for palliation. In the second part of the duodenum, the area of the papilla appeared with an infiltrating mass associated with an irregular, ulcerated aspect of the mucosa. The ampulla of Vater was involved by the tumoral process due to the malignant infiltration by the adjacent pancreatic tumor. Biopsies were not performed to avoid the risk of bleeding.

7. Cholangiography 03'13''

The cholangiography showed a 20mm diameter common bile duct, with no intraluminal filling: no defects or strictures.

8. Sphincterotomy 03'06''

A small sphincterotomy was performed using Endocut current.

9. Stent insertion 03'26''

The guidewire was then left in place and a 10 French, 6cm long, uncovered Wallflex® stent was inserted. Under fluoroscopy and endoscopic guidance, the stent was delivered in such a way that its lower part would not be involved in further tumor growths: it was positioned around 2cm out of the papilla. The stent placement resulted in relief of the obstructive jaundice. In conclusion, endoscopic metal stenting of the common bile duct for palliative treatment of inoperable pancreatic cancer is safe and less invasive when compared to the alternative surgical or radiological treatments, and has a superior clinical outcome in the hands of experts.