S5242 PTBD-EDGE Rendezvous for Malignant Biliary Obstruction and Afferent Loop Syndrome in Surgically Altered Anatomy After Failure of Conventional Approaches

Introduction: Pancreatic cancer, particularly borderline resectable pancreatic head carcinoma, poses major challenges due to its aggressiveness, anatomical complexity, and frequent complications. We present a complex case illustrating the use of a percutaneous transhepatic biliary drainage (PTBD)–endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) rendezvous, a rarely described approach for achieving biliary access and internal drainage. Case Description: A 68-year-old man with borderline resectable pancreatic head carcinoma underwent neoadjuvant chemotherapy. The patient developed malignant gastric outlet obstruction (MGOO), requiring a Roux-en-Y gastrojejunostomy. Due to tumor progression, chemotherapy was switched to palliative regimen. Exploratory laparotomy revealed unresectability. Upon further progression, the tumor infiltrated the gastroenterostomy and led to superior mesenteric vein thrombosis, causing recurrent MGOO and portocaval collateral formation with repeated upper GI bleeding. A partial gastrectomy, revision of the gastrojejunostomy, and creation of a splenorenal (Warren) shunt were performed. Intensive systemic therapy was resumed. Three years later, malignant distal biliary obstruction occurred. Endoscopic ultrasound-guided biliary drainage was not feasible due to perigastric collaterals. Enteroscopic endoscopic retrograde cholangiopancreatography (E-ERCP) failed due to adhesions and an inaccessible afferent loop. Thus, PTBD with same-session uncovered metal stent (UC-SEMS) placement was initiated. Fluoroscopy during PTBD revealed an afferent loop syndrome, making standard stenting ineffective due to impaired aboral bile flow. A percutaneous drain was placed, and the afferent loop filled with water to facilitate endoscopic ultrasound-guided gastroenterostomy using an electrocautery-enhanced lumen-apposing metal stent (HotAXIOS 15 mm × 10 mm). Via this access, EDGE with PTBD rendezvous (PTBD-EDGE) enabled successful UC-SEMS placement (Wallflex Biliary RX, 10 mm × 60 mm) for definitive biliary decompression. Eleven months later, stent dysfunction due to tumor ingrowth was effectively managed by EDGE-assisted intraductal radiofrequency ablation (id-RFA, Habib EndoHPB probe, 10 W, 90 s, bipolar soft mode). Discussion: This case underscores the importance of individualized, multidisciplinary care in advanced pancreatic cancer. Combined percutaneous and advanced endoscopic techniques can provide effective palliation, even in highly complex clinical situations.