Endoscopic Ultrasound-Guided Choledochoduodenostomy as Palliative Treatment: A Challenging Case Report

We report the case of an 88-year-old female with obstructive jaundice due to a periampullary tumor. The patient developed acute cholangitis and consequent clinical deterioration, so it was decided to perform palliative biliary drainage. Due to duodenal tumor invasion, it was not possible to perform endoscopic retrograde cholangiopancreatography. A different approach was attempted and it was decided to carry out an endoscopic ultrasound-guided choledochoduodenostomy. This procedure was performed with a linear echoendoscope, and using a duodenal bulbar approach, a fistula was created between the bulb and the common bile duct. A self-expandable fully covered metal biliary stent was placed in the common bile duct under endoscopic and fluoroscopic guidance, allowing biliary drainage. The patient presented clinical improvement. However, 3 weeks after being discharged, she was readmitted to our department with hematemesis associated with the migration of the biliary stent to the duodenal bulb. Endoscopic hemostasis was performed but the patient had multiple bleeding relapses that were controlled through arterial embolization. Despite the migration of the biliary stent, the fistula between the duodenum and the common bile duct remained patent, allowing a successful palliation of the obstructive jaundice. Therefore, despite the occurred complication, we admitted a technical and clinical success of the endoscopic ultrasound-guided choledochoduodenostomy. This is an emerging technique and a valuable alternative for palliative biliary drainage in cases of malignant distal obstruction. This clinical report supports this finding, reporting technical aspects of the procedure, associated complications and their management as well as the clinical outcomes.