Taylor A. Romdenne, BS1, Julia Bosco, BS2, John Bosco, MD3; 1Advocate Aurora Research Institute, Green Bay, WI; 2Medical College of Wisconsin, Milwaukee, WI; 3Aurora Medical Group, Green Bay, WI
Introduction: Distal malignant biliary obstruction (MBO) is often caused by pancreatic malignancies constricting the bile duct. In this case report, the HOT AXIOS™ stent was used for transgastric gallbladder drainage following failed ERCP biliary drainage and attempted EUS directed transluminal biliary decompression in a patient with stage IV pancreatic cancer and recurrent MBO, resulting in durable relief of jaundice.
Methods: A 65-year-old male presented with abdominal pain and jaundice. Upon examination, symptoms were attributed to a dilated common bile duct, pancreatic duct and fullness in the pancreatic head with bilirubin levels of 5.9 mg/dL. Following endoscopic ultrasound and fine needle aspiration (FNA) the patient was found to have a 2.5 cm mass at the pancreas head with 1.6 cm attachment to the portal vein – which was determined to be stage IV pancreatic cancer. A biliary stent was placed resulting in biliary decompression and jaundice resolution.
Six months later the patient presented for evaluation of adverse events as a result of cytotoxic chemotherapy. Upon workup the patient was jaundiced with elevated bilirubin (6.0 mg/dL). CT showed the previously placed biliary stent had migrated out of the bile duct and was promptly replaced. Eighteen months later the patient presented with jaundice and recurrent MBO with duodenal invasion. Imaging revealed the complete migration of the stent. The duodenum was narrowed and fibrotic, prohibiting ERCP. After failed traditional attempts of stent placement for drainage, a 10 mm HOT AXIOS™ transenteric stent was placed directly into the gallbladder from the duodenal bulb. A 4 cm double-pigtail Hobbs medical stent was deployed through the AXIOS stent into the gallbladder as an adjunctive stent. This approach provided gallbladder decompression and resolved the patient’s jaundice and bilirubin (0.5 mg/dL), allowing chemotherapy treatment to be resumed. Discussion: To our knowledge, the novel use of the HOT AXIOS™ system is unique in its intended purpose to drain the gallbladder to afford effective biliary decompression. This palliative option may be an effective management technique for second line decompression in future patients.
Disclosures: Taylor Romdenne indicated no relevant financial relationships. Julia Bosco indicated no relevant financial relationships. John Bosco indicated no relevant financial relationships.