Supplementary Material for: A challenging case of recurrent cholangitis caused by isolated bile duct metastasis of colorectal adenocarcinoma – rescue therapy through EUS-guided hepaticoesophagostomy.

A 64-year-old male was admitted with fever, abdominal pain and jaundice. Medical history was relevant for colorectal adenocarcinoma eleven years before and right hepatectomy due to liver metastasis. MRCP revealed left hepatic duct stenosis without liver nodules. ERCP was performed for biliary drainage with plastic stents. After inconclusive brush cytology, cholangioscopy (Spyglass™DS2) was performed showing villous mucosa surrounded by irregular vessels suggestive of tumor neovascularization. Spybite™ biopsies confirmed biliary metastasis of colorectal origin.
The patient started palliative chemotherapy being readmitted six months later with acute cholangitis. Diffuse infiltrating intrabiliary lesion with 120mm was detected in control MRCP. Given its intraductal extension and gastric compression by the hypertrophied liver leading to duodenoscope mispositioning, transpapilar stents could not be deployed. Multiorgan dysfunction developed despite broad-spectrum antibiotics and EUS-guided biliary drainage was proposed. Although EUS access was limited by gastric bulging, puncture of a dilated intrahepatic duct was accomplished with a 19G needle. PCSEMS (GIOBOR™8x100mm) placement was only possible above the gastroesophageal junction with the proximal flare being incidentally deployed in a 3cm intraparietal esophageal tract. The misplaced stent was immediately recanalized and a stent-in-stent FCSEMS (Wallflex™80x10mm) allowed the hepaticoesophagostomy creation. Since the stent opening was orally oriented in esophageal lumen, parenteral nutrition was started to avoid contamination. Sepsis recovering and liver tests normalization were observed.
Before hospital discharge stent reposition was planned to resume oral feeding. After placement of a third stent-in-stent NCSEMS (Wallflex™120x10mm) in the hepaticoesophagostomy to prevent migration, the proximal flare was oriented to the stomach gently pushing with the endoscope aiding by an inflated biliary balloon. The patient resumed chemotherapy but died 8 months after due to disease progression.
Isolated bile duct metastasis is an uncommon complication of colorectal cancer. EUS-guided hepaticoesophagostomy is feasible when puncture through the esophagus was inevitable, especially in patients with liver hypertrophy.