The majority of the patients who present with adenocarcinoma of the pancreatic head present with clinical jaundice. Internal biliary drainage via retrograde placement of an endobiliary stent is the preferred method of biliary drainage in these patients. ERCP with internal biliary drainage can be performed safely and generally with less short- and long-term morbidity compared with percutaneous transhepatic approaches to biliary drainage. Accordingly, patients at M. D. Anderson with clinical evidence of jaundice undergo ERCP with endobiliary stent placement and EUS with EUS-guided FNA in the same sedation period. This allows for relief of jaundice and tissue diagnosis in a single, 2-step procedure.
There is also a subset of patients who present with persistent or progressive jaundice following failed attempts at endobiliary stent placement before referral. Many of these patients can undergo successful biliary decompression when ERCP is attempted again under optimal conditions in more experienced hands. If the second ERCP is unsuccessful, we generally palliate jaundice using percutaneous transhepatic means. This provides early relief of jaundice and access to the biliary tree for subsequent therapeutic procedures. A percutaneous transhepatic catheter (PTC) can be advanced into the duodenum and capped off to facilitate internal biliary drainage. Alternatively, many patients with transhepatic biliary drains can undergo successful retrograde endobiliary stent placement performed as a secondary procedure after initial percutaneous transhepatic drainage. When this approach is used, a wire is advanced through the existing PTC, which is then withdrawn, leaving the wire extended through the PTC tract and across the ampulla into the duodenum. Immediate endoscopy is then performed, and the wire is used to guide an endo-biliary stent retrograde across the stricture. This strategy often allows for removal of the PTC, which, even when capped off, causes discomfort for the patient and can be associated with significant morbidity.
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