Pancreatic cancer remains one of the most lethal malignancies, with a persistently low five-year survival rate and substantial global mortality. Surgery remains the only curative option, but most patients are not surgical candidates at diagnosis, and palliative radiotherapy and chemotherapy remain the only ways to improve survival. The progression of pancreatic adenocarcinoma is often associated with complications, such as biliary obstruction and gastric outlet obstruction (GOO).

This case report describes a 57-year-old male patient with pancreatic ductal adenocarcinoma who underwent successful endoscopic management of common complications associated with the disease. These included biliary obstruction, treated with EUS-guided hepaticogastrostomy and EUS-guided gallbladder drainage, and gastric outlet obstruction, managed through endoscopic gastroenterostomy.

Through this clinical case, we aim to demonstrate that minimally invasive interventions not only relieve symptoms but also improve the patient’s quality of life, emphasizing the evolving role of endoscopy in the therapeutic management of pancreatic ductal adenocarcinoma. These challenges underscore the importance of a multidisciplinary approach to optimize therapeutic strategies.

pancreatic carcinoma, biliary obstruction, gastric outlet obstruction, EUS-guided gastroenterostomy, EUS-guided hepaticogastrostomy, EUS-guided gallbladder drainage, multidisciplinary approach

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers, with a poor 5-year survival rate, and it ranks as the seventh leading cause of cancer-related deaths globally. Depending on tumor location and disease progression, PDAC commonly leads to complications such as biliary obstruction, gastric outlet obstruction, and pain. Endoscopic ultrasound (EUS) has long been a critical tool for diagnosing and local staging PDAC. Over the last decade, EUS has evolved from a primarily diagnostic modality to an effective therapeutic tool, especially with advancements in technologies like lumen-apposing metal stents (LAMS), enabling the treatment of PDAC complications as alternatives to surgery (Han and Papachristou 2024).

EUS-guided techniques, such as EUS-guided gastroenterostomy (EUS-GEA), EUS-guided hepaticogastrostomy (EUS-HGS), and EUS-guided gallbladder drainage (EUS-GBD), have become vital in managing complex PDAC cases. EUS-GEA is used to treat gastric outlet obstruction by creating a bypass between the stomach and small intestine, allowing for quicker resumption of oral intake. EUS-HGS provides an alternative biliary drainage route when ERCP is not feasible, ensuring effective decompression of the bile ducts. EUS-GBD is a safe and effective option for patients with bile duct obstruction or acute cholecystitis who are not suitable for surgery, relieving inflammation and preventing recurrence.

These minimally invasive EUS-guided procedures offer promising alternatives to traditional surgical approaches, improving patient safety, recovery times, and overall quality of life. With continued advancements in endoscopic technology, these techniques are becoming increasingly integral to managing PDAC.

A 57-year-old male presented with abdominal pain, postprandial heaviness, bloating, and significant weight loss of 10 kg over several months. Initial imaging revealed a locally advanced tumor in the head of the pancreas with cranial extension and critical duodenal stenosis. During the initial hospitalization in the clinic, the patient presented with vomiting, prerenal acute kidney injury, and electrolyte imbalances. Imaging findings were consistent with gastric obstructive syndrome. To address these complications, an endoscopic ultrasound-guided gastroenterostomy (Fig. 1) was performed to bypass the duodenal stenosis, restore gastric emptying, and improve oral intake. An endosonography-guided biopsy was taken from the tumor, which confirmed the diagnosis of ductal adenocarcinoma. Afterward, the patient was referred for chemo- and radiotherapy, which he tolerated well. However, laboratory evaluations during follow-up revealed progressive jaundice, necessitating further intervention. This was followed by EUS-guided gallbladder drainage, which relieved bile duct obstruction, normalized bilirubin levels, and provided significant symptomatic improvement. This technique was chosen because the left intrahepatic bile ducts were not sufficiently dilated, and endoscopic ultrasound-guided hepaticogastrostomy was initially not possible. However, several months later, the patient experienced recurrent jaundice, necessitating further interventions.

Figure 1. 

А. Echoendoscopic image of the target loop (up) and LAMS placement (down) in EUS-GEA; B. Fluoroscopic image of LAMS placement in the target loop.

An EUS-guided hepaticogastrostomy (Fig. 2) was then performed to manage the recurrent biliary obstruction, involving stent placement between the stomach and the intrahepatic bile ducts. This successfully resolved the jaundice. Additionally, the patient underwent surgical hernioplasty to repair a combined direct and indirect inguinal hernia, which proceeded without complications and resulted in a smooth recovery.

Figure 2. 

EUS-guided hepaticogastrostomy. A. Left hepatic duct puncture and contrast injection, endoscopic ultrasound image; B. Placement of a self-expanding metal stent.

Follow-up imaging confirmed the patency of the stents (Fig. 3). The patient underwent four cycles of gemcitabine-based chemotherapy and palliative radiotherapy, both of which were well tolerated. Conservative measures, including parenteral nutrition, therapeutic paracentesis, prokinetics like Domperidone, and diuretic therapy with Furosemide and Spironolactone, were implemented to manage ascites and maintain his quality of life. Despite disease progression, the patient maintained a good quality of life and was able to work until the final months of his illness. Combining endoscopic, surgical, and supportive therapies ensured effective symptom control and good functional status.

Figure 3. 

CT reconstruction of the patient’s anatomy demonstrating: A. EUS-guided gastroenterostomy (EUS-GEA) with a lumen-apposing metal stent (LAMS); B. EUS-guided gallbladder drainage (EUS-GBD) with LAMS and a double pigtail stent; C. EUS-guided hepaticogastrostomy (EUS-HGS) with a GIOBOR stent connecting the left hepatic duct to the stomach.

The management of pancreatic ductal adenocarcinoma often requires a combination of innovative endoscopic, surgical, and systemic approaches to address its complex complications. This case highlights the significant role of EUS-guided interventions in symptom control and improving quality of life. Endoscopic stenting, particularly EUS-guided gastroenterostomy, EUS-guided gallbladder drainage, and hepaticogastrostomy, has emerged as a transformative modality in the palliative management of PDAC complications. In this case, EUS-GEA provided an effective bypass for duodenal stenosis, enabling oral intake and improving nutritional status. Studies have consistently shown that EUS-GEA is a superior alternative to duodenal stenting in gastric outlet obstruction cases. For instance, a prospective multicenter study from Spain reported a 98.5% technical success rate for EUS-GEA, with 75.4% of patients restarting oral intake within seven days and 84.4% tolerating a normal diet by 30 days​ (Garcia-Alonso et al. 2023).

Compared to duodenal stenting, EUS-GEA has been associated with longer stent patency and fewer reinterventions. An international multicenter randomized trial (Teoh et al. 2023) found that EUS-GEA resulted in a significantly lower 6-month reintervention rate (4% vs. 29%) and improved gastric outlet obstruction scores, with no difference in adverse events​. Similarly, a large retrospective study from Spain observed that EUS-GEA had improved 3-month stent patency rates (92.2% vs. 80.6%) compared to duodenal stenting​. While randomized trials directly comparing EUS-GEA with surgical gastroenterostomy are lacking, retrospective studies and meta-analyses suggest that EUS-GEA is superior in terms of shorter hospital stays, faster time to oral intake, and lower adverse event rates (Kumar et al. 2022; Sánchez-Aldehuelo et al. 2022).

Similarly, biliary obstruction is a common complication in pancreatic cancer (Kloek et al. 2010), with ERCP being the method of choice for biliary drainage (Seo et al. 2019); however, its use can be limited in cases where tumor infiltration of the papilla or duodenum or surgically altered anatomy makes the procedure technically impossible. In such scenarios, EUS-guided techniques, including choledochoduodenostomy (EUS-CD), hepaticogastrostomy, and gallbladder drainage, provide practical and effective alternatives for biliary decompression. This approach is supported by studies indicating high clinical success rates for EUS-HG, such as the 94% clinical success rate reported in a two-center retrospective study from Japan, with adverse events like peritonitis occurring in only 4.4% of cases​ (Nakai et al. 2020). Furthermore, EUS-guided gallbladder drainage (EUS-GBD) has proven to be a reliable salvage modality, with studies showing clinical success rates exceeding 90% and low rates of adverse events​ (Imai et al. 2016; Issa et al. 2021).

EUS-guided biliary drainage has shown superiority over traditional percutaneous transhepatic biliary drainage (PTBD) in cases of complex biliary obstruction due to advanced PDAC. For example, a multicenter randomized trial from Korea found that EUS-guided techniques had a lower adverse event rate (8.8% vs. 31.2%) and shorter hospital stays compared to PTBD​ (Lee et al. 2016). Similarly, combining EUS-GE with EUS-biliary drainage as a “double bypass” has proven effective, with higher clinical success and fewer adverse events compared to surgical alternatives like hepaticojejunostomy and gastrojejunostomy​ (Bronswijk et al. 2023).

Despite being highly effective, EUS-guided procedures are not without challenges. In this case, recurrent biliary obstruction required multiple interventions, a common issue noted in studies where reintervention success rates remain high. For example, a Japanese study reported a 100% success rate in addressing recurrent biliary obstructions following EUS-HG (Inoue et al. 2023). Close follow-up and timely reintervention are critical to maintaining symptom control and quality of life. Furthermore, managing GOO in PDAC presents unique challenges. Tumor progression and stent misdeployment remain potential risks; however, advances in lumen-apposing metal stents have minimized these complications​.

The strategy followed in this case aligns with the latest studies and guidelines advocating for EUS-guided techniques in the management of PDAC complications. The 2021 ESGE guidelines highlight the effectiveness of EUS-guided gastroenterostomy, hepaticogastrostomy, and gallbladder drainage as minimally invasive alternatives for managing complications of pancreatic cancer, recommending their use in expert centers for gastric outlet obstruction, biliary drainage, and high-risk patients, respectively, due to their safety and reduced need for reinterventions (Van der Merwe et al. 2022).

While addressing the patient’s complex complications with stenting and advanced endoscopic procedures, it is important to note that vascular toxicities, influenced by mechanisms such as endothelial dysfunction, procoagulant states, and metabolic disturbances, may also play a role in cancer treatment outcomes. These factors, though not the primary focus in this case, underscore the importance of comprehensive care in such scenarios (Zlatanova et al. 2024).

This case underscores the complexity of managing advanced pancreatic ductal adenocarcinoma and highlights the critical role of a multimodal approach in achieving optimal patient outcomes. Through the strategic use of therapeutic endoscopic interventions, effective symptom control was attained, with complementary measures such as systemic therapy, radiotherapy, and supportive care contributing to the maintenance of the patient’s quality of life and functional status. Despite the progressive nature of the disease, this integrative approach allowed the patient to maintain meaningful daily activities into the later stages of the illness. Thus, illustrating the value of combining innovative endoscopic techniques with comprehensive oncological and supportive therapies.

As nonsurgical therapies for PDAC continue to advance, endoscopy is expected to play an increasingly important role in managing biliary and gastroduodenal obstructions. The treatment of complications will likely expand, as endoscopic techniques offer an effective means of delivering local therapies to the primary tumor. Beyond safety and efficacy, the cost implications of new endoscopic interventions will be crucial in their implementation. The costs associated with these procedures should be balanced by reductions in hospitalization duration and frequency, as well as measurable improvements in quality of life. For patients with PDAC, the decision to proceed with endoscopic interventions should be made through a multidisciplinary discussion involving the patient and surgical, medical oncology, and gastroenterology experts (Coté and Sherman 2012).

Conflict of interest

The authors have declared that no competing interests exist.

Ethical statements

The authors declared that no clinical trials were used in the present study.

The authors declared that no experiments on humans or human tissues were performed for the present study.

The authors declared that no informed consent was obtained from the humans, donors or donors’ representatives participating in the study.

The authors declared that no experiments on animals were performed for the present study.

The authors declared that no commercially available immortalised human and animal cell lines were used in the present study.

Funding

No funding was reported.

Author contributions

All authors have contributed equally.

Author ORCIDs

Petko Karagyozоv https://orcid.org/0000-0002-2297-547X

Nadica Shumka https://orcid.org/0009-0004-8217-8183

Data availability

All of the data that support the findings of this study are available in the main text.