Endoscopic translumen-apposing metal stent biliary stent placement

A 58-year-old woman with a history of stage IV pancreatic adenocarcinoma, who had received a 10-mm × 10-mm lumen-apposing metal stent (LAMS; Boston Scientific, Marlborough, Mass) choledochoduodenostomy and a 22-mm × 60-mm duodenal stent (Boston Scientific) for biliary ductal obstruction and gastric outlet obstruction presented with obstructive jaundice and symptoms including epigastric pain, nausea, and vomiting. A CT scan revealed enlarged liver metastases and increased left biliary dilation (Fig. 1A). We chose to endoscopically stent the left biliary obstruction through the pre-existing LAMS placed 3 months prior (Video 1, available online at www.VideoGIE.org).

Figure 1.

A, CT scan showing the duodenal stent at the far left and the adjacent choledochoduodenostomy lumen-apposing metal stent (LAMS). Immediately superior to the short-axis LAMS is biliary dilation that extends deep into the liver. B, Endoscopic view of the sphinctertome between the LAMS on the left and the duodenal stent at the right with its phalanges protruding toward the endoscope. The LAMS was filled with debris. C, Fluoroscopic view illustrating dilation of the proximal biliary duct and lack of contrast medium in the left biliary system. D, Fluoroscopic view of placement of a biliary stent through the LAMS and into the strictured left biliary branch.

Using a side-viewing 41.1F endoscope (TJF-Q180V, Olympus America, Chelmsform, Mass), we visualized the choledochoduodenostomy occluded with debris (Fig. 1B). A 39-mm sphinctertome (Boston Scientific) was passed through the LAMS, and contrast medium showed a stricture at the branch of the left biliary system and upstream dilation (Fig. 1C). A 0.025-inch guidewire was advanced into the left biliary system, followed by a straight 7F × 9 cm stent (Olympus America) placed across the stricture with complete drainage of the biliary tree (Figs. 1C and D). A plastic biliary stent was chosen because of its easier maneuverability compared with the rigidity of the metal stent catheter. A metal biliary stent with a larger diameter would occlude or block the contralateral biliary system.

Over the next week, the patient’s bilirubin normalized and remained normal until 8 weeks later, when her disease progressed. Two weeks before this admission, she completed cycle 3 of chemotherapy, which was stopped 2 months after her discharge when she opted for comfort care.

Our case demonstrates an endoscopic technique to safely access the left biliary tree through a LAMS choledochoduodenostomy in a patient with metastatic disease who was a high-risk surgical candidate.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

A step-by-step description of endoscopic intubation of the LAMS with a sphinctertome, followed by fluoroscopic illustration of the dilated and strictured biliary, then placement of a biliary stent through the LAMS and into the left biliary branch.