S5363 Unique Problems and Unique Solutions: A Case Necessitating Endoscopic Ultrasound-guided Antegrade Cholangiopancreatography (EACP)

Introduction: Endoscopic ultrasound-guided (EUS) biliary drainage has emerged as a valuable alternative in cases where conventional endoscopic retrograde cholangiopancreaticography (ERCP) is unsuccessful. If the papilla is inaccessible, we revert to EUS guided drainage with either choledochoduodenostomy (EUS-BD) or hepaticogastrostomy (HGS). We present a unique case of malignant distal biliary obstruction (MDBO) and duodenal obstruction eventually necessitating EACP. Case Description: A 64-year-old man with metastatic prostate cancer underwent abdominal MRI for restaging, which revealed an incidental 3.6 cm pancreatic head mass causing MDBO. The proximal common bile duct (CBD) was 10 mm with a distal stricture in the area of the mass. The patient was symptomatic, with a bilirubin of 4.6 mg/dL. ERCP was attempted, however, tumor infiltration led to severe duodenal stricturing, preventing passage of the ERCP scope or gastroscope. Therapeutic options were discussed with the patient, which included HGS, percutaneous transhepatic biliary drainage (PTBD), or EACP. We did not offer EUS-BD due to the small caliber of the CBD and tumor infiltration within the duodenal bulb. The patient elected for EACP due to a preference to preserve the natural drainage pathway. A 19-gauge EUS-FNA needle was used to puncture a branch of the left intrahepatic duct, and a cholangiogram confirmed positioning. A 0.025” guidewire was advanced into the CBD but even after numerous attempts, we could not traverse the stricture. We then used a needle knife sphincterotome (NKS) to negotiate through the gastric wall, liver capsule, and biliary epithelium. With the NKS in the proximal CBD, we exchanged the 0.025” wire for a 0.035” wire and were able to negotiate this across the stricture into the small bowel. We then performed segmental dilatation of the liver parenchyma using a 4 mm balloon to allow for passage of the stent catheter while minimizing the risk of bile leakage. A 10 mm × 80 mm uncovered metal stent was deployed across the stricture with contrast drainage confirmed. The patient recovered uneventfully and was discharged 2 days later with a normalized bilirubin. Discussion: EACP is not a commonly used technique for drainage of MDBO due to its technical challenges and higher risk of bile leakage. This technique was used for our patient to preserve the natural drainage pathway while avoiding PTBD. EACP should remain available in the arsenal of every advanced endoscopist who manages MDBO.