Case Report

Single-Session Ultrasonography Guided Fine-Needle Biopsy, Choledochoduodenostomy, and Duodenal Stenting in Advanced Pancreatic Cancer: A Case Report

by Giorgio Valerii1*, Filippo Vernia2, Salvatore Longo3, Carlo Cellini1, Giovanni Latella2, Carmelo Barbera1

1Gastroenterology Unit, G. Mazzini Hospital, Teramo, Italy.

2Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy.

3Endoscopy Unit, Villa Sofia Cervello Hospital, Palermo, Italy.

*Corresponding author: Giorgio Valerii, 1Gastroenterology Unit, G. Mazzini Hospital, Teramo, Italy.

Received Date: 06 February 2024

Accepted Date: 12 February 2024

Published Date: 14 February 2024

Citation: Valerii G, Vernia F,  Longo S, Cellini C, Latella G, et al. (2024) Single-Session Ultrasonography Guided Fine-Needle Biopsy, Choledochoduodenostomy, and Duodenal Stenting in Advanced Pancreatic Cancer: A Case Report and Literature Review. Ann Case Report 09: 1641. https://doi.org/10.29011/2574-7754.101641.

Abstract

Background: Advanced pancreatic cancer is often diagnosed with local and distal extension, it can involve the common bile duct and/or duodenum. The inability to cannulate the papilla may preclude the performance of Endoscopic Retrograde Cholangio Pancreatography (ERCP). Endoscopic diagnosis and treatment with duodenal stenting and Endoscopic Ultrasonography (EUS)guided biliary drainage with specifically designed, fully covered, self-expandable (Hot-AXIOS, Boston Scientific Corp, Natick, USA) can be challenging but feasible. Case presentation: We report the case of a 72-year-old patient affected by obstructive jaundice due to locally advanced pancreatic cancer, determining as well gastric outlet obstruction. EUS, performed from the duodenal bulb, determined the presence of a neoplasm (42x47mm) in the pancreatic head. The lesion, infiltrating portal- and mesenteric vein, and the gastroduodenal artery. A Fine-Needle Biopsy (FNB) of the lesion was performed with a 22-Gauge needle.  During the same endoscopic session through the duodenal bulb wall a 8mmX8mm Luminal Apposing Metal Stent (LAMS) Hot-AXIOS was placed under EUS guidance, leading to effective biliary drainage. A duodenal, 18x10cm partially covered Self-Expandable Metal Stent (SEMS) was subsequently positioned. No early or late complications were observed. Conclusions: A single-step endoscopic approach for diagnosis and palliative treatment with stenting of advanced pancreatic cancer is feasible and effective.         

Keywords: Choledochoduodenostomy; Pancreatic Head Adenocarcinoma; Duodenal Stenting; EUS-FNB

Introduction

Pancreatic Head Adenocarcinoma (PHAC) is a highly aggressive malignancy [1]. Being often asymptomatic, early diagnosis is uncommon and 5-year survival is low [1].  When symptoms occur, most patients are unfit for curative surgery. Obstructive jaundice (82% cases) and gastric outlet obstruction (GOO) (10-20%) result from advanced infiltration of the Common Bile Duct (CBD) and duodenum, respectively [2–4]. Obstructive Jaundice is a condition that need endoscopic/radiological treatment. The quality of life is markedly improved by endoscopic palliation and preservation of oral feeding in patients with GOO [3,4].

Endoscopic Retrograde Cholangiopancreatography (ERCP) with stenting of the common biliary duct thus represents the first line therapeutic approach for extrahepatic obstructive jaundice. However, the access to major papilla may not be feasible whenever the PHAC obstructs the duodenal lumen and Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) represents a valid alternative procedure to ERCP [5–7]. A further advantage of EUS resides in the possibility to provide histological biopsy specimens to confirm diagnosis [8].

Simultaneous duodenal stenting and EUS-BD have been reported in few cases characterized by concomitant malignant biliary and duodenal obstructions (Table1).

Author

Design

No. Patients

Biliary drainage

Type of malignancy

Iwamuro et al. [9]

Retrospective

2

7

Pancreatic, ampullary

Kanno et al. [10] (abstract)

Retrospective

6

6

NA

Khashab et al. [11]

Retrospective

3

9

Pancreatic, duodenal, other

Maluf-Filho et al. [12]

Retrospective

5

5

Pancreatic, other

Pan et al. [13]

Retrospective

1

5

Pancreatic, ampullary, bile duct, gallbladder

Tonozuka et al. [14]

Retrospective

4

8

Pancreatic

Sanchez-Ocana et al. [15]

Retrospective

9

24

Pancreatic, gastric, other

Brewer Gutierrez

et al. [16]

Retrospective

7

7

Pancreatic

Matsumoto et al. [17]

Retrospective

19

19

Pancreatic, ampullary, gastric, bile duct, gallbladder, metastatic

Hamada et al. [18]

Retrospective

20

20

Pancreatic, ampullary, gastric, bile duct, gallbladder, other

Anderloni et al. [19]

Case series

4

4

Pancreatic

total

80

114

Table 1: Review of literature on single-session double stenting: endoscopic ultrasound-guided biliary drainage and duodenal stent for combined biliary obstruction and Gastric Outlet Obstruction (GOO).

A single step approach helps avoiding repeated endoscopic procedures under anaesthesia, and minimizes the patient discomfort, the risk of adverse events and healthcare costs.

A case of a single-session endoscopic procedure associating EUS-FNB, EUS-guided choledochoduodenostomy, and duodenal stenting in a patient with locally advanced head pancreatic cancer is reported.

Case Presentation

A 72-year-old man presented with jaundice, weight loss, fatigue, nausea, vomiting and abnormal liver functional tests (LFTs) with high level of amylase and lipase; kidney functional tests were normal.

The past medical history included high blood pressure, impaired glucose tolerance and benign prostatic hyperplasia, well controlled by medical treatment.

An abdomen Computed Tomography (CT) scan with intravenous contrast revealed a hypo-vascular large head pancreatic lesion (42x47mm), infiltrating portal and mesenteric veins and the celiac axis. Local lymph nodes were also involved by metastases, resulting in a stage III (T4, N2, and M0) PHAC [20]. A bilio-pancreatic EUS was performed, confirming the pancreatic lesion, with increased stiffness and reduced enhancement after endovascular EUS contrast SonoVue (Bracco Spa, Milan, Italy). The intrahepatic ducts, as well as the Common Bile Duct (CBD) and the pancreatic duct were markedly dilated (15mm and 6mm, respectively) prompting drainage.

Although the imaging features were highly suggestive of PHAC, FNB (three passes) was performed with an Acquire 22 Ga needle (Boston Scientific, Natick, MA) to characterize the lesion (Figure 1). An attempt to reach the ampulla with a duodenoscope failed due to the presence of a stenosing, ulcerated mass involving the major papilla and EUS-Guided Biliary Drainage (EUS-BD) was thus carried out.

 

Figure 1: A. Endoscopic ultrasonography-guided fine-needle biopsy of pancreatic head mass. B.  Histology of the biopsy shows signs of pancreatic cancer.

Results

The EUS-BD was performed, at first, Fine Needle Aspiration (FNA) of the CBD from the duodenal bulb with a Expect 19 Ga needle (Boston Scientific, Natick, Mass) after, when bile drainage confirmed the correct positioning of the needle in the CBD, a 0.035inch guidewire was placed in the biliary system. A lumen apposing metal stent catheter (LAMS) HOT AXIOS™ (Boston Scientific Corp., Marlborough, MA) 8X8 mm was released from the wall of the duodenal bulb, through guidewire, up to the common bile duct under EUS and fluoroscopic control (Figure 2).