ERCP and EUS Procedures: ERCP and EUS Procedures: Malignant Duct Drainage

0:00Welcome to Board Pearls. This is episode three of seven of the ERCP and EUS Procedures chapter, in the Endoscopic Procedures module. This episode is draining a bile duct blocked by cancer. The first patient is a man with pancreatic cancer about to start chemotherapy, and his case shows why a fully covered metal stent comes first and whether every resectable tumor should be drained before surgery. The second patient is a woman with a hilar tumor, and her case shows why the answer flips to an uncovered stent at the hilum, how much liver must be drained to clear jaundice, and when a plastic stent is right after all. The third patient is a woman whose papilla can't be reached, and her case shows the rescue when endoscopic retrograde cholangiopancreatography, ERCP, fails: what makes endoscopic ultrasound, EUS, guided drainage possible, and how to choose among rendezvous, choledochoduodenostomy, and hepaticogastrostomy. A man with gastric bypass and a hilar tumor shows the last of those three.

1:02Here's the first patient. He's the sixty-nine-year-old man from episode two, with a three-centimeter pancreatic head adenocarcinoma confirmed by EUS biopsy. His bilirubin is eleven and he's very itchy. His tumor is borderline resectable, and his oncologist plans four to six months of neoadjuvant modified FOLFIRINOX before surgery.

1:22He has malignant distal biliary obstruction ahead of months of chemotherapy. Three things decide a stent for malignant obstruction: where the obstruction is, whether the tumor is resectable, and how long the patient is expected to live. The type and configuration of the stent then depend on the stricture's location and the side-branch anatomy around it. His obstruction is distal, he's heading for chemotherapy and then surgery, and his life expectancy is many months.

1:52Those three answers point to a fully covered self-expanding metal stent. For distal obstruction from pancreatic head adenocarcinoma, distal cholangiocarcinoma, or ampullary cancer in a patient awaiting neoadjuvant therapy, the pathway is EUS-guided fine-needle biopsy of the mass plus same-session ERCP with a fully covered metal stent, combining tissue and drainage under one anesthetic to shorten the time to chemotherapy. The reason is durability. A fully covered metal stent gives four to six months of patency, spanning his chemotherapy, and it's removable at the Whipple operation, while its covering prevents tumor ingrowth that would block an uncovered stent. A plastic stent typically stays open for about three months and needs a repeat ERCP to replace it, which delays surgery and adds procedural risk. He has both procedures in one session, his bilirubin falls, his itch settles, and his chemotherapy starts on time.

2:48His drainage was needed because of his chemotherapy, and not every resectable tumor should be drained. A randomized trial of routine preoperative drainage in resectable pancreatic head cancer without cholangitis or severe jaundice showed no benefit and more complications. So routine drainage before prompt surgery is no longer standard. Drainage is still indicated for cholangitis, severe jaundice that interferes with chemotherapy, or planned neoadjuvant therapy, and he has two of the three. A patient with a small, clearly resectable tumor, a bilirubin of four, no cholangitis, and surgery scheduled next week goes straight to the operating room.

3:29At the hilum, the choice of stent reverses, and the second patient shows why. A seventy-six-year-old woman has unresectable hilar cholangiocarcinoma, Bismuth-Corlette type four, meaning tumor involving both the right and left intrahepatic ducts. Her bilirubin is fourteen, and her expected survival with treatment is more than three months. Her magnetic resonance cholangiopancreatography, MRCP, shows both lobes dilated and a small, atrophic left lateral segment.

3:58For unresectable hilar cholangiocarcinoma of Bismuth types three or four, perihilar cholangiocarcinoma, or gallbladder cancer with bilateral intrahepatic dilation, with life expectancy over three months, uncovered metal stents are preferred. A covered stent's membrane would block the orifices of the side branches at the confluence, which are the very ducts the procedure is trying to drain, while an uncovered mesh lets bile from those branches flow through. So the same goal is reached with opposite designs: in the distal duct there are no side branches to block, and the covering prevents tumor ingrowth, while at the hilum the covering becomes the problem.

4:36Her drainage is planned by volume rather than by anatomy alone. The goal is to drain at least fifty percent of the viable liver on cross-sectional imaging, because that's the threshold above which jaundice resolves; below it, cholestatic injury persists despite the procedure. MRCP comes first to define which territories are viable. Atrophic territories aren't stented, because entering them introduces infection without any drainage benefit. Bilateral stenting is favored when both lobes hold similar volumes of viable liver, and unilateral stenting is enough when one lobe is atrophic and the other holds most of the viable liver.

5:12Her images decide which ducts get stents. Her right lobe is large and viable, her left medial segment is viable, and her left lateral segment is atrophic. So an uncovered metal stent is placed into her right system, draining well over half of her viable liver, and her bilirubin falls from fourteen to three over two weeks. If her jaundice had persisted, her viable left medial territory would have been drained as well. Had her right lobe been atrophic and her left large, the left would have been stented: viable volume decides, and the image comes before the choice of duct.

5:46Plastic stents still have a place, decided by survival. They're reserved for life expectancy under three months, because their shorter patency doesn't justify the procedure in longer-surviving patients, while their lower cost suits a brief survival, such as a frail patient with widespread metastases and weeks to live. A gallbladder cancer invading the porta hepatis with bilateral dilation and a longer expected survival gets the same uncovered metal plan as her tumor, because the rule follows the anatomy of the obstruction, not the name of the cancer. And if any of these stents blocks and causes cholangitis, drainage follows the Tokyo timing: within twenty-four hours for severe disease and within forty-eight hours for moderate disease.

6:29When ERCP can't reach the papilla at all, EUS offers the rescue, and the third patient shows when that's needed. A sixty-four-year-old woman has unresectable pancreatic head adenocarcinoma with liver metastases, a bilirubin of sixteen, and a week of vomiting. Her computed tomography, CT, shows a sixteen-millimeter common bile duct and tumor invading the second part of her duodenum. At ERCP, the duodenoscope couldn't pass her duodenal narrowing, and her papilla was never seen. Her oncologist wants her jaundice relieved so she can have palliative chemotherapy.

7:04She has failed ERCP for malignant distal obstruction with a dilated duct, and EUS-guided biliary drainage is the modern rescue. From the duodenum or stomach, EUS shows the dilated extrahepatic or intrahepatic ducts. The duct is punctured under ultrasound guidance and outlined with contrast, and then one of three finishes is chosen, depending on whether the papilla can be reached, whether the extrahepatic duct is approachable, and what the anatomy and the operator's expertise allow. Every option starts with a needle into a dilated duct, so without a dilated duct, none of them is available. Hers is sixteen millimeters.

7:41The first option, rendezvous, is preferred when the papilla can be reached but cannulation has failed. The duct is punctured from the duodenal bulb, usually into the extrahepatic duct, or from the stomach into the left intrahepatic duct. A guidewire is advanced through the puncture, across the stricture, and out through the papilla into the duodenum, and then a duodenoscope retrieves the wire and completes the ERCP over it. Rendezvous restores natural drainage through the papilla without creating a permanent fistula, preserving the anatomy for future procedures, and it's the last step in the difficult-cannulation sequence. Her duodenoscope can't reach her papilla, so rendezvous isn't possible for her.

8:20Her option is EUS-guided choledochoduodenostomy, used when the papilla can't be reached, because of gastric outlet obstruction, duodenal tumor invasion, or altered anatomy, but the dilated extrahepatic duct is accessible from the duodenal bulb. A lumen-apposing metal stent, LAMS, is deployed across a new fistula from the bulb into the extrahepatic duct. Its two flanges hold the duodenal and duct walls together so the tract matures without a bile leak, and bile drains directly into the duodenum, bypassing the obstructed papilla. It's the standard rescue for distal malignant obstruction after failed ERCP. Her bulb sits above the duodenal narrowing and her duct is wide, so she has an EUS-guided choledochoduodenostomy. Her bilirubin falls from sixteen to four in a week, with internal drainage instead of a percutaneous tube, and her duodenal obstruction is addressed separately.

9:13The third option is needed when neither the papilla nor the extrahepatic duct can be reached, and a fourth patient shows it. A fifty-eight-year-old man had a Roux-en-Y gastric bypass ten years ago and now has unresectable hilar cholangiocarcinoma, with markedly dilated left intrahepatic ducts and dilated right ducts that are harder to reach. A standard duodenoscope can't reach his papilla, the extrahepatic duct isn't where his obstruction is, and his left ducts are visible from the gastric pouch. He needs EUS-guided hepaticogastrostomy, used when neither the papilla nor the extrahepatic duct is accessible, as in hilar obstruction with an isolated intrahepatic territory, a prior Whipple, or Roux-en-Y bypass, but a dilated left intrahepatic duct is visible from the proximal stomach.

10:00His stent is designed around the complication this procedure is known for. A dilated left intrahepatic duct is punctured from the stomach, and a partially covered metal stent or a dedicated hepaticogastrostomy stent is placed across the gastric wall into the duct. The covered part prevents bile leaking along the tract, and the uncovered part inside the liver keeps the side branches draining. Stent migration into the peritoneum was historically among the most feared and most frequent complications, because the gastric wall moves and only a short length of stent sits inside the liver. So dedicated stents combine a covered tract segment with an uncovered segment inside the duct, plus flares and retention flaps that resist displacement. With these stents, migration has become uncommon, and bleeding, bile leak, and cholangitis are now among the most frequent adverse events, along with stent occlusion from food debris or tumor ingrowth. He has a hepaticogastrostomy with a dedicated stent and is watched for bleeding, leak, and cholangitis. If left-sided drainage doesn't clear his jaundice, the volume goal may require draining his right side, for example percutaneously. ERCP after gastric bypass is covered in episode four.

11:12Choosing among the three follows an order: rendezvous, then choledochoduodenostomy, then hepaticogastrostomy, as the anatomy allows. The goal is to preserve natural drainage and avoid creating a fistula when possible, with operator expertise and the availability of dedicated devices also deciding. Rendezvous leaves no fistula. Between the two fistula options, the duodenal one is preferred when the extrahepatic duct can be reached, because hepaticogastrostomy places a stent through a mobile stomach into a short length of liver. Percutaneous transhepatic drainage remains the alternative when EUS drainage isn't possible.

11:50Here are the traps the boards set in malignant obstruction. A plastic stent isn't placed before months of chemotherapy, and an uncovered stent isn't placed in a distal stricture before a planned Whipple. Biopsy and drainage are combined in one session when they can be. Resectable disease isn't drained routinely before prompt surgery unless there's cholangitis, severe jaundice, or planned neoadjuvant therapy. A covered stent isn't used at the hilum. An atrophic segment isn't stented, and the goal is half the viable liver, not every duct. And a metal stent isn't used when survival is under three months.

12:23For EUS drainage, the traps are these. Choledochoduodenostomy isn't chosen when the papilla can be reached for rendezvous, and rendezvous isn't possible when it can't. Hepaticogastrostomy isn't chosen when the extrahepatic duct is accessible. A hepaticogastrostomy gets a partially covered or dedicated stent, not a fully covered one. Migration is its classic complication. And EUS drainage depends on a dilated duct.

12:52So, start to finish. For distal malignant obstruction, sample by EUS and drain with a fully covered metal stent in the same session, especially before neoadjuvant therapy, because it lasts four to six months and comes out at surgery. Don't drain resectable disease routinely before prompt surgery. At the hilum, use uncovered metal stents to drain at least half of the viable liver on MRCP, avoiding atrophic segments. Use plastic only when survival is under three months.

13:20When ERCP fails and the duct is dilated, drain by EUS: rendezvous if the papilla is reachable, choledochoduodenostomy with a LAMS if only the extrahepatic duct is, and hepaticogastrostomy with a dedicated, partially covered stent if only a left intrahepatic duct is, watching for migration, bleeding, leak, and cholangitis.

13:43Episode four is ERCP when surgery has changed the anatomy: gastric bypass, hepaticojejunostomy, and Billroth two.

13:53For the full chapter, the practice vignettes, and the topic-tagged question bank, head to board pearls dot com. You'll find the rest of the series on Apple Podcasts, Spotify, or wherever you listen to podcasts. That brings us to the end of episode three of seven of chapter twenty-nine, and I'll see you in the next one.