P2762 - Biliary Drainage of Hilar Cholangiocarcinoma Using Bilateral Pancreatic Duct Stents

Henry Lam, DO¹, Desire Guthier, DO², Matthew J. Sullivan, DO³, Michal Kloska, MD², Shashin Shah, MD^2
1Lehigh Valley Health Network, Easton, PA; ²Lehigh Valley Health Network, Allentown, PA; ³Eastern Pennsylvania Gastroenterology and Liver Specialists, Allentown, PA

Introduction: Hilar cholangiocarcinoma (hCCA) is a tumor of the biliary tree at the confluence of the main hepatic ducts. It has a poor prognosis with less than 10% five-year survival rate. Symptoms may include signs of biliary obstruction, abdominal pain, weight loss, or cholangitis. Management often involves endoscopic stenting to relieve biliary obstruction, serving as a bridge to surgery or for palliation. Here we feature a series of patients with hCCA who underwent biliary drainage using pancreatic duct stents with significant clinical and biochemical improvement.

Case Description/Methods: Three patients with no relevant medical history presented with abdominal pain. Patient 1 was a 79-year-old female with dark urine, light-colored stools, and pruritus. Patient 2 was a 69-year-old female with pruritus and 25-pound weight loss in six months. Patient 3 was a 55-year-old male with no other symptoms. Lab work for each patient showed liver function abnormalities with imaging suspicious for hCCA. Each underwent EUS and ERCP with dilation of stricture and placement of pancreatic duct stents. Shortly after, each patient had gradual resolution of clinical symptoms and marked improvement in total bilirubin levels as noted in Table 1 and Figure 1. Patient 1 underwent stereotactic body radiation therapy as she was not a surgical candidate. Patients 2 and 3 had extensive surgical resection with adjuvant chemotherapy. Final diagnoses were confirmed with biopsy findings consistent with ductal adenocarcinoma.

Discussion: While endoscopic stenting is widely utilized in the management of hCCA, no guidelines exist regarding this matter. To the best of our knowledge, this is the first case series to document the use of pancreatic duct stents to relieve biliary obstruction. Unique features of the pancreatic duct stents include the soft polymer construction aiding in stent placement and multiple internal side holes allowing for better drainage and patency. This may explain the rapid improvement seen in our patients. A prior study showed that it takes an average of 2.7-5.6 weeks for initial total bilirubin to normalize to ≤ 2 mg/dL after placement of conventional biliary duct stents. Each of our patients had at least a 74% reduction in total bilirubin within 2-7 days of stent placement. Given the efficaciousness demonstrated, future research examining the utility of pancreatic duct stents is warranted. While stenting has not been shown to improve mortality, it aids in the resolution of symptoms and increases quality of life.


Figure: Reduction in total bilirubin levels after placement of bilateral pancreatic duct stents for each patient.

Patient	Bismuth Classification	Peak TB (mg/dL)	Post Stent TB (mg/dL)	Days Post Stent	Stent Characteristics
1	I	15.6	3.4	3	B/L 7 Fr x 13 cm single external pigtail
2	II	21.3	5.4	2	R 7 Fr x 11 cm single external pigtail L 7 Fr x 13 cm single external pigtail
3	II	6.7	1.4	7	B/L 7 Fr x 13 cm single external pigtail

Table: Reduction in total bilirubin (TB) levels after placement of bilateral pancreatic duct stents with Bismuth Classification and stent characteristics for each patient.


Disclosures:
Henry Lam indicated no relevant financial relationships.
Desire Guthier indicated no relevant financial relationships.
Matthew Sullivan indicated no relevant financial relationships.
Michal Kloska indicated no relevant financial relationships.
Shashin Shah indicated no relevant financial relationships.


Henry Lam, DO¹, Desire Guthier, DO², Matthew J. Sullivan, DO³, Michal Kloska, MD², Shashin Shah, MD². P2762 - Biliary Drainage of Hilar Cholangiocarcinoma Using Bilateral Pancreatic Duct Stents, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.