Endoscopic management of occluded biliary Wallstents: a cancer center experience

BACKGROUND: Biliary obstruction caused by unresectable malignancy commonly is treated by placement of a biliary self-expandable metallic stent. The endoscopic and percutaneous techniques for self-expandable metallic stent placement are well established and can be performed with a high success rate. Self-expandable metallic stent placement affords palliation of pruritus and enables treatment of advanced cancer with chemotherapeutic agents metabolized by the liver. Unfortunately, these stents tend to occlude with time. Optimal management of an occluded self-expandable metallic stent remains to be determined. METHODS: A retrospective review was undertaken to determine optimal management of the occluded self-expandable metallic stent. Patients with malignant biliary obstruction who had endoscopic management for occluded Wallstents that had been placed percutaneously and endoscopically were studied. All patients underwent ERCP with one of the following interventions: mechanical cleaning, insertion of a plastic stent within the Wallstent, or insertion of a second Wallstent. The effectiveness of the intervention and duration of stent patency thereafter was studied. RESULTS: A total of 34 patients with occluded biliary Wallstents underwent the following procedures: mechanical cleaning (6 patients), placement of a second Wallstent (4), or insertion of a plastic stent (24). Mechanical cleaning was effective in only one of 6 patients. For all 4 patients who underwent placement of a second Wallstent, there was resolution of jaundice or cholangitis and no reocclusion. Plastic stent insertion was successful in 22 of 24 patients. Median duration of stent patency after intervention was 192 days (range 81-257 days) after second Wallstent placement, 90 days (11-393 days) after plastic stent insertion, and 21 days (3-263 days) after mechanical cleaning. Duration of stent patency was better when the initial malignant stricture involved the distal vs. the proximal bile duct. CONCLUSIONS: Occlusion of a biliary Wallstent is best managed by endoscopic insertion of a second Wallstent or a plastic stent. Mechanical cleaning is less effective. The level of the initial biliary obstruction influences stent patency.     

Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis.

BACKGROUND & AIMS: Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice. METHODS: A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended. RESULTS: Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal, $19,935; (2) plastic f/u metal, 20,157 dollars; (3) metal f/u plastic, 20,871 dollars; and (4) plastic f/u plastic, 20,878 dollars. For initial plastic stents to be preferred over short-length metal stents, 70% or more of pancreatic cancers would need to be potentially resectable by pancreaticoduodenectomy. CONCLUSIONS: In patients undergoing ERCP before definitive cancer staging, short-length SEMS is the preferred initial cost-minimizing strategy.     

Combined brush cytology and stent placement in a single session for presumed malignant biliary stricture

Background and Aim: Biliary stricture may be benign or malignant and causes obstructive jaundice. Brush cytology is a simple technique for diagnosing the cause of biliary stricture; however, its sensitivity has been reported to be low. A technique that comprises diagnosing the cause of stricture with a satisfactory sensitivity and relieving jaundice is required. This study was designed to evaluate the diagnostic performance of brush cytology and the feasibility of the subsequent stent placement in a single endoscopic retrograde cholangiopancreatography (ERCP) session performed for presumed malignant biliary strictures. Methods: Data were collected by reviewing the medical records of 100 consecutive patients with suspected malignant biliary stricture who underwent brush cytology followed by stent placement at our center. Diagnostic performance of brush cytology, completion rate of the whole procedures comprising brush cytology and stent placement, and complications were evaluated. Result: Sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of brush cytology were 83%, 100%, 100%, 33% and 84%, respectively. Biliary stent was successfully inserted for all patients (100%) subsequent to brush cytology in a single ERCP session. Eight patients (8%) had complications. Conclusion: Brush cytology was performed with much higher sensitivity of 83% than those of previous reports and the subsequent stent placement was successfully completed in all cases. For presumed malignant biliary stricture, brush cytology should be selected as an initial attempt because this technique is simple and enables subsequent stent placement in a single ERCP session.     

内镜胆道内支架引流治疗伴肝脏转移的胰头癌16例

目的:评价伴肝脏转移的胰头癌患者内镜胆道内支架引流治疗的临床意义.方法:门诊就诊和转院的胰头癌伴有肝脏转移患者,如具有严重的梗阻性黄疸则符合内镜逆行胆胰管造影救治指征,然后按照知情同意的原则进入治疗研究计划.均应用内镜胆道内支架引流技术,包括金属内支架和塑料支架.治疗出院后随访观察至患者死亡.结果:16例患者进入治疗研究,其中伴有腹膜后淋巴结转移5例.均采用内镜胆道支架引流术,其中应用胆道金属支架12例,胆道塑料支架4例,胰管内支架6例.治疗后1 wk时梗阻性黄疸缓解率100%,精神状况明显好转75.0%(12/16),食欲改善25.0%(4/16),睡眠改善37.5%(6/16).治疗后的患者最短生存期为9d,最长生存期为134 d,平均81.4 d±50.2 d.随访数据表明治疗有意义的97%,治疗效果满意的11例.结论:对于伴有肝脏转移的胰头癌患者,内镜胆道内支架引流技术不仅能解除梗阻性黄疸,而且可以一定程度的改善生存质量,具有一定的临床应用价值.     

Late-onset severe biliary bleeding after endoscopic pigtail plastic stent insertion

Here, we report our experience with a case of severe biliary bleeding due to a hepatic arterial pseudoaneurysm that had developed 1 year after endoscopic biliary plastic stent insertion. The patient, a 78-year-old woman, presented with hematemesis and obstructive jaundice. Ruptured hepatic arterial pseudoaneurysm was diagnosed, which was suspected to have been caused by long-term placement of an endoscopic retrograde biliary drainage(ERBD) stent. This episode of biliary bleeding was successfully treated by transarterial embolization(TAE). Pseudoaneurysm leading to hemobilia is a rare but potentially fatal complication in patients with long-term placement of ERBD. TAE is a minimally invasive procedure that offers effective treatment for biliary bleeding.     

ERCP and Stent Therapy for Progressive Jaundice in Hepatocellular Carcinoma (Which Patients Benefit, Which Patients Don't?)

Jaundice in hepatocellular carcinoma (HCC) canbe due to biliary obstruction. Endoscopic retrogradecholangiopancreatography (ERCP) can be both diagnosticand therapeutic. Biliary stenting can relieve jaundice and allow further chemotherapy, but atadditional expense and potential morbidity. We sought todetermine whether CT scan or ultrasound (US) couldidentify which patients with HCC and jaundice wouldbenefit from endoscopic stenting. We retrospectivelyanalyzed 26 patients with HCC and jaundice who underwentERCP after CT or US. We compared biliary dilation on CTor US with the dominant biliary stricture seen on ERCP, and with response to biliary stenting.Eleven of 26 patients had dominant biliary stricture onERCP; 11 underwent stenting. Six of 11 (55%) stentedpatients had a significant decline in bilirubin; three became eligible for further chemotherapy.All six responders to stenting had biliary dilation onprior CT or US. Procedure-related complications occurredin 1/11 (9%) who underwent stent placement. In conclusion, in selected patients, stentingcan safely relieve jaundice and allow subsequentchemotherapy. CT or US accurately predicted lesions thatresponded to stenting. ERCP and stenting provided no benefit in the absence of biliary dilationon CT or US.     

ENDOSCOPIC SPHINCTEROTOMY PLUS ENDOPROSTHESES IN THE TREATMENT OF LARGE OR MULTIPLE COMMON BILE DUCT STONES

Background and Aim: Little information is available on the outcomes of endoscopic sphincterotomy plus biliary stent placement without stone extraction as primary therapy at initial endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of large or multiple common bile duct (CBD) stones. The aim of the present study was to study the effect of biliary stents and sphincterotomy as primary therapy for patients with choledocholithiasis. Methods: Patients with large (≥20 mm) or multiple (≥3) CBD stones were retrospectively studied. The patients underwent endoscopic sphincterotomy and placement of plastic stents in the bile duct without stone extraction at the initial ERCP. Three or more months later, a second ERCP was carried out and stone removal was attempted. Differences in stone size and the largest CBD diameter before and after stenting were compared. Stone clearance and complications were also evaluated. Results: 52 patients were enrolled. After a median of 124 days of biliary plastic stent placement the mean maximal stone diameter decreased from 16.6 mm to 10.0 mm (P < 0.01). The mean CBD diameter also decreased from 15.3 mm to 11.5 mm (P < 0.01). The total stone clearance at second ERCP was 94.2%, only 5.7% of which needed mechanical lithotripsy. Complications: pancreatitis in one (1.9%) at initial ERCP, cholangitis in two (3.8%) after 52 days and 84 days of placement of stent. No complications were recorded at second ERCP. Conclusions: Biliary plastic stents plus endoscopic sphincterotomy without stone extraction as primary therapy at initial ERCP is a safe and effective method in the management of large or multiple CBD stones.     

Stent implantation through rendezvous technique of PTBD and ERCP: the treatment of obstructive jaundice

OBJECTIVE: To study the technical method and clinical value of stent implantation through the rendezvous technique of percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice. METHODS: Thirty-six patients with obstructive jaundice underwent the rendezvous technique of PTBD and ERCP after initially unsuccessful ERCP. RESULTS: The procedure of 36 cases were all successful. Sixteen cases underwent PTBD drainage from the bile duct through the right lobe approach and in 20 cases the left lobe approach was used. The one-stage procedure involved in the rendezvous technique of PTBD and ERCP was successful in 23 cases, while the other 13 cases underwent PTBD first and then rendezvous ERCP the next time. The serum total bilirubin 4 days later had decreased by 44.75%, and direct bilirubin had decreased by 45.61%. The main complication was infection of the bile duct. CONCLUSION: Stent implantation using the rendezvous technique of PTBD and ERCP is a new and feasible method to treat obstructive jaundice after initially unsuccessful ERCP. This may be of considerable value in clinical practice.     

Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.

Twenty patients with chronic pancreatitis and signs of biliary obstruction were treated by endoscopic placement of self expandable metal mesh stents, and followed up prospectively. Eleven had been treated previously with plastic endoprostheses. All had persistent cholestasis, seven patients had jaundice, and three overt cholangitis. Endoscopic stent placement was successful in all cases. No early clinical complication was seen and cholestasis, jaundice or cholangitis rapidly resolved in all patients. Mean follow up was 33 months (range 24 to 42) and consisted of clinical evaluation, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 18 patients, successive ERCPs and cholangioscopies have shown that the metal mesh initially embeds in the bile duct wall and is rapidly covered by a continuous tissue by three months. The stent lumen remained patent and functional throughout the follow up period except in two patients who developed epithelial hyperplasia within the stent resulting in recurrent biliary obstruction, three and six months after placement. They were treated endoscopically with standard plastic stents with one of these patients ultimately requiring surgical drainage. No patient free of clinical or radiological signs of epithelial hyperplasia after six months developed obstruction later. This new treatment could become an effective alternative to surgical biliary diversion if further controlled follow up studies confirm the initial impression that self expandable metal mesh stents offer a low morbidity alternative for longterm biliary drainage in chronic pancreatitis without the inconvenience associated with plastic stents.     

奥曲肽联合ERCP＋留置内支架对胰头癌治疗效果的临床分析

目的 探讨奥曲肽联合ERCP＋留置内支架治疗胰头癌并阻塞性黄疸患者的临床价值.方法 收集2006年1月至2011年12月武汉市中心医院消化内科收治的99例并发阻塞性黄疸的胰头癌患者,采用随机、平行对照的方法分为治疗组及对照组.对照组51例患者仅采用ERCP及留置内支架减黄治疗,治疗组48例患者在内镜治疗的同时给予奥曲肽0.1 mg皮下注射,每日2次,连续治疗90d以上,直至病死.观察治疗前后患者血胆红素水平的变化;恶心、呕吐、腹痛、腹泻、纳差等症状的改善情况;治疗发生的并发症及患者的生存时间.结果 对照组患者治疗后6例再次出现黄疸,考虑支架阻塞,其中3例再次行内支架植入后黄疸消退,3例未再次行支架置入.其余45例及所有治疗组患者的血胆红素均下降至基本正常（低于正常值的2倍）.治疗前两组患者恶心、呕吐、腹痛、腹泻、纳差的发生率差异均无统计学意义,治疗后两组患者上述症状的发生率均较治疗前明显下降,且治疗组的下降显著优于对照组,差异均有统计学意义（P值均＜0.05）.对照组有3例术后发生急性胰腺炎,治疗后缓解.治疗组无1例术后发生胰腺炎,但有3例注射部位发生皮肤疼痛,经更换注射部位后疼痛缓解.对照组患者平均生存时间为（7.3±5.3）个月,治疗组为（14.4±8.7）个月,差异有统计学意义（P＜0.05）.结论 奥曲肽联合ERCP＋留置内支架治疗胰头癌并阻塞性黄疸患者能明显改善患者生存质量,延长患者的生存时间.     

Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing,self-expandable fully covered metal stent for palliative biliary drainage

In addition to the poor prognosis associated with pancreatic adenocarcinoma, it can also lead to several other conditions including obstructive jaundice that can affect a patient’s quality of life. This is a major concern in non-operative patients where palliation is considered the main therapeutic goal. Traditionally, there are several ways to pursue palliative biliary drainage including endoscopic methods, a variety of surgical procedures, and percutaneous techniques. Generally, endoscopic methods such as endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement are considered first-line therapies. Unfortunately, ERCP is not always possible due to several potential reasons. Although endoscopic ultrasound-guided biliary puncture has been well described for several years, there are limitations to its usefulness in biliary drainage, in part due to complication concerns. However, more recently a lumen-apposing, self-expandable fully covered metal stent has been employed for such situations. We describe two cases in which this type of stent was used in patients for palliative biliary drainage in pancreatic adenocarcinoma where standard ERCP was not feasible. In both cases, stent deployment was successful without immediate complications related to the procedure or the stent. Furthermore, the main goal of these therapies was palliation and in both cases the patient chose this procedure for quality of life reasons. In the future, randomized trials are needed to better define the long-term effectiveness and safety of these stents compared to more standard therapies.     

Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography

Endoscopic ultrasonography （EUS）-guided biliary drainage was performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography （ERCP）. In the present study, we introduced the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients who failed in ERCR We performed the procedure in 2 papilla of Vater, including one resectable case, and 2 cases of cancer of the head of pancreas. Using a curved linear array echoendoscope, a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Using a biliary catheter for dilation, or papillary balloon dilator, a 7-Fr plastic stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. In 3 （75%） of 4 cases, an indwelling plastic stent was placed, and in one case in which the stent could not be advanced into the bile duct, a naso-biliary drainage tube was placed instead. In all cases, the obstructive jaundice rapidly improved after the procedure. Focal peritonitis and bleeding not requiring blood transfusion was seen in one case. In this case, pancreatoduodenectomy was performed and the surgical findings revealed severe adhesion around the choledochoduodenostomy site. Although further studies and development of devices are mandatory, EUS-guided choledochoduodenostomy appears to be an effective alternative to ERCP in selected cases.     

Biliary hemostasis using an endoscopic plastic stent placement for uncontrolled hemobilia caused by transpapillary forceps biopsy (with video)

A 78-year-old woman was referred to our hospital for the examination and treatment of jaundice. A transpapillary forceps biopsy for a long distal bile duct stricture was performed using endoscopic retrograde cholangiopancreatography. Immediately after the biopsy, massive bleeding was observed from the orifice of the papilla. Although hemobilia was pulsatile, an endoscopic biliary plastic stent placement was very effective in achieving hemostasis. However, a nasal biliary catheter was required because a blood clot clogged the stent on the following day. Although covered self-expandable metal stent (CSEMS) placement has been reported for achieving endoscopic hemostasis for bleeding, we chose to use a plastic stent to reduce the risk of post-procedure pancreatitis. The placement of both an endoscopic biliary plastic stent and a nasobiliary drainage catheter can be an alternative hemostatic tool to CSEMSs.     

塑料支架内引流在老年难取性胆管结石中的应用

目的:回顾性分析在老年性难取性胆总管结石患者中胆道塑料支架置入治疗的安全性和有效性.方法:先行常规逆行性胆胰管造影(ERCP)明确诊断,根据胆管扩张及结石大小情况,行十二指肠乳头括约肌切开后经导丝引导放置胆道塑料支架通畅引流.结果:103例取石困难患者在常规ERCP后置入塑料支架.3-6mo后复查ERCP显示有60例(58.2%)结石成为小结石,经内镜应用网篮取出;13例(12.6%)结石未变化,重新更换支架引流;11例(10.6%)最后行腹腔镜胆囊切除胆管探查取石治疗;16例(15.5%)患者因无特殊不适未复查ERCP,长期行内支架引流.结论:对于老年性难取性胆管结石患者,塑料支架内引流是一种十分有效和相对安全的手术方式.     

肝门区转移癌所致梗阻性黄疸的内镜支架引流治疗临床效果分析

目的探讨内镜治疗肝门区转移癌所致梗阻性黄疸的临床应用价值。方法2006年开始随机选择自愿应用内镜治疗的晚期肝门区转移癌所致梗阻性黄疸患者,应用内镜胆道塑料内支架技术解除胆道梗阻,观察操作成功率、生存期等评价指标。共治疗肝门转移癌梗阻性黄疸患者38例,其中肝癌13例,胆囊癌3例,胃癌14例,食管癌2例,回肠腺癌1例,胰腺癌5例。结果所有患者治疗成功且临床黄疸完全消退,随访生存期92～521d,平均（185．42±104．41）d。随访观察5例患者更换胆道支架,更换时间3～14个月,平均（8．6±4．1）个月,其中支架移位1例,胆泥阻塞2例,肿瘤阻塞2例。结论内镜支架引流术是肝门区转移癌所致梗阻性黄疸的一种有效治疗方法,具有较高的治疗成功率,可以一定程度延长患者的生存期。     

Removal of an embedded "covered" biliary stent by the "stent-in-stent" technique

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction.A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography(ERCP)and cytology was benign.A 6 cm fully covered self-expanding metal stent(SEMS)was inserted across the stricture to optimize biliary drainage.However,the SEMS could not be removed at repeat ERCP a few months later.A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later.Fully covered biliary(SEMS)are used to treat benign biliary strictures.This is the first reported case of inability to remove a fully-covered biliary SEMS.Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally,or chemical or mechanical damage to the polymer covering of the stent.Application of the stent-in-stent technique allowed successful retrieval of the initial stent.     

Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice. Recently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) using double-balloon enteroscopy (DBE) has been shown to be feasible and effective, even in patients with surgically altered anatomies. On the other hand, endoscopic partial stent-in-stent (PSIS) placement of self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible, safe and effective. We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success. This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization, even in patients with surgically altered anatomies.     

内镜在胰胆管合流异常诊疗中的作用探讨

目的探讨ERCP在胰胆管合流异常中的诊断价值,评估内镜治疗的效果。方法16例胰胆管合流异常（PBM）患者,通过ERCP造影进行PBM分型,结合临床症状,分析引起相关疾病的机制、影像特点,根据合并的其它胰胆疾病,选择适当的内镜取石、扩张或引流等治疗,观察治疗效果。结果16例胰胆管合流异常患者多伴有腹痛、呕吐、黄疸等症状,及转氨酶和／或淀粉酶水平的升高。其中,Ⅰ型（B—P型）7例,Ⅱ型（P—B型）5例,Ⅲ型（复杂型）4例;合并胆总管囊肿扩张10例,无扩张者5例,胆管癌并狭窄1例;伴有胆管结石11例（4例为蛋白栓）、胰管结石2例（1例不伴胆管结石）。9例予内镜下胆管取石,2例胰管取石,术中置入胆道支架引流7例,行鼻胆管引流3例,胰管支架置入5例,胆道金属支架置人1例。术后临床症状均明显缓解。结论ERCP是一种可靠的诊断手段,其分型与PBM相关疾病表现有明显相关,选择性、暂时性的内镜治疗在外科术前是有效的、必要的。     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.     

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis,a novel technique for malignant obstruction:A case report and review of literature

For patients suffering from both biliary and duodenal obstruction,endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the treatment of choice.ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct(CBD).We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma.The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.