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our hospital with obstructive jaundice. Abdominal computed tomography re− vealed a hypovascular mass in the head of the pancreas, dilatation of the bile ducts, and tumor invasion into the second portion of the duodenum (l" Fig. 1). Small nodules were also observed in the omentum, and a diagnosis of pancreatic cancer with peritonitis carcinomatosa was made. After percutaneous transhepa− tic biliary drainage (PTBD) was per− formed to relieve the jaundice, a duode− nal self−expandable metallic stent was deployed in the duodenal stricture (l" Fig. 2, 3). Informed consent was ob− tained, and then a convex linear−array echo endoscope (GF−UCT2000; Olympus Co. Ltd., Tokyo, Japan) was used to punc− ture the dilated extrahepatic bile duct at the level of the duodenal bulb with an Olympus KD−10Q−1 needle−knife, using an electrosurgical generator (ICC200; ERBE, Tübingen, Germany). After the nee− dle−knife was removed from the catheter, a guide wire was introduced into the bile duct under fluoroscopic guidance, and the catheter was removed. A 7−Fr biliary plastic stent (Flexima; Cook Endoscopy, Winston−Salem, North Carolina, USA) was then inserted into the left hepatic bile duct (l" Fig. 4). Once this procedure was complete, the PTBD catheter was re− moved (l" Fig. 5). Endoscopic ultrasound−guided biliary drainage from the duodenal bulb has been reported recently [1 ± 3]. If a patient has both a distal biliary stricture and a duodenal stricture around the major pa− pilla, a biliary metallic stent can be de− ployed via the PTBD route. However, and particularly in patients with peritonitis carcinomatosa, recurrent cholangitis can occur because duodenal contents can re− flux into the bile duct when a biliary me− tallic stent is deployed beyond the major papilla [4]. As a result, patients can re− quire external biliary drainage. We sug− gest that endoscopic ultrasound−guided choledochoduodenostomy can be an ef− fective treatment for patients who have a duodenal stent over the major papilla and peritonitis carcinomatosa.

Combined endoscopic ultrasound-guided choledochoduodenostomy and duodenal stent placement in a patient with pancreatic cancer