Forward-viewing echoendoscope provides single sessional three biliary drainage routes in a patient with pancreatoduodenectomy

In patients with pancreatoduodenectomy, echoendoscopic intubation to the hepaticojejunostomy site on the jejunal limb is necessary to visualize the perihilar area ¹ . Therefore, intubation of a forward-viewing curvilinear echoendoscope (FV-CLS) may be considered when balloon enteroscopy-assisted cholangiopancreatography fails ^{1 2 3} . A dedicated partially covered self-expandable metal stent (PCSEMS) with an excellent anchoring system has been developed for use in endoscopic ultrasound-guided biliary drainage (EUS-BD) ^{4 5} . Herein, we present the initial FV-CLS intubation, which provided three single-session biliary drainage routes, in a patient with perihilar recurrence after pancreatoduodenectomy.

An 84-year-old woman who underwent pancreatoduodenectomy with modified Child reconstruction for stage IIB pancreatic cancer was referred to our hospital due to perihilar obstruction with a dilated biliary tree ( Video 1 ). Our biliary drainage strategy involved direct cannulation of the biliary anastomosis or EUS-BD via the anastomosis site or residual stomach, all of which were attempted in a single session using FV-CLS (TGF-UC260J; Olympus Medical Systems, Tokyo, Japan). The FV-CLS was advanced into the reconstructed alimentary tract. However, the left intrahepatic biliary branch was 3.1 mm in diameter on endosonography of the residual stomach ( Fig. 1 , Video 1 ), and the anastomosis was obscured owing to tumor involvement ( Fig. 2 , Video 1 ). Therefore, we selected EUS-BD via the anastomosis site as follows: a 19-gauge needle puncture with a 0.025-inch guidewire advancement to the left bile duct, a 4-mm balloon dilation, and a PCSEMS (Niti-S Spring Stopper, 8 mm/10 cm; Taewoong Medical, Gimpo, Korea) deployment ( Fig. 3 , Video 1 ). The patient’s clinical course was uneventful.

Fig. 1.

Left intrahepatic biliary branch depicted by forward-viewing curved linear echoendoscope (FV-CLS) from the residual stomach. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) via the residual stomach was likely achieved; however, we hesitated to perform a puncture because the left intrahepatic biliary branch was narrow (3.1 mm in diameter).

Fig. 2.

Biliary anastomosis area on the jejunal limb in the endoscopic view of FV-CLS. We sought a biliary anastomosis point for cannulation; however, this was challenging because of the deformity caused by tumor invasion.

Fig. 3.

EUS-BD via the anastomosis site on the jejunal limb using FV-CLS.  a FV-CLS revealed perihilar recurrence obstructing the dilated left hepatic duct after pancreatoduodenectomy. EUS-BD was feasible via the anastomosis site. Yellow solid arrows indicate the left hepatic duct involved in tumor recurrence.  b A 19-gauge needle with a 0.025-inch guidewire was then advanced into the left hepatic duct.  c A partially covered self-expandable metal stent with an antimigration system recanalized the obstruction.

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Forward-viewing echoendoscope provides single sessional three biliary drainage routes in a patient with pancreatoduodenectomy.

Video 1

Direct intubation with FV-CLS potentially provides three biliary access routes in a single session for patients with pancreatoduodenectomy and reconstruction, followed by biliary obstruction caused by perihilar recurrence: first, cannulation to the anastomosis if visible; second, EUS-BD via the afferent limb; and third, EUS-BD via the residual stomach.

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