S5215 Overcoming ERCP Limitations: A Case of EUS-Guided Biliary Stenting in Pancreatic Cancer-Induced Obstructive Jaundice

Introduction: Pancreatic cancer frequently leads to malignant biliary obstruction, often managed with endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP is not always feasible, particularly in cases with duodenal stenosis. Endoscopic ultrasound (EUS)-guided antegrade biliary stenting (EUS-AGS) has emerged as an alternative approach. This case illustrates the successful use of EUS-AGS in an 80-year-old man with pancreatic cancer-induced obstructive jaundice where ERCP was not possible. Case Description: An 80-year-old man with a history of pancreatic adenocarcinoma presented with fever, chills, altered mental status, and progressive jaundice. Laboratory findings included an elevated total bilirubin of 4.1 mg/dL, which worsened to 7.7 mg/dL, alongside a rise in AST/ALT and alkaline phosphatase. Imaging revealed a periampullary mass causing severe biliary obstruction and duodenal stenosis, precluding ERCP. After a failed ERCP, EUS-AGS was performed via a transgastric puncture of the left intrahepatic bile duct using a 19-gauge needle. A guidewire was successfully passed across the biliary obstruction, followed by dilation and placement of an uncovered metal stent in the common bile duct. Post-procedure, the patient showed marked clinical and biochemical improvement, with bilirubin levels decreasing to 1.3 mg/dL. He was discharged without complications and continued outpatient follow-up. Discussion: EUS-AGS is gaining recognition as a viable alternative to percutaneous transhepatic biliary drainage (PTBD) and ERCP when conventional methods are unfeasible. Compared to PTBD, EUS-AGS offers lower complication rates, improved patient comfort, and reduced hospital stays. This case reinforces the safety and efficacy of EUS-AGS for managing distal malignant biliary obstruction, particularly in the setting of gastric outlet obstruction.