Technique Video
EUS-guided biliary rendezvous as an emergent rescue after a failed choledochoduodenostomy using a lumen-apposing metal stent.
Abbreviations: CBD, common bile duct; CDS, choledochoduodenostomy; EC-LAMS, lumen-apposing metal stent with an electrocautery-enhanced delivery system; RV, rendezvous
A 60-year-old man with pancreatic cancer and liver metastases who had been referred previously for biliary drainage was recommended palliative oncologic treatment. After a failed transpapillary attempt via ERCP, same-session EUS-guided biliary drainage was chosen. On EUS examination, a minimally dilated common bile duct (CBD) up to 9 mm was identified from the duodenal bulb. An EUS-guided choledochoduodenostomy (CDS) using a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EC-LAMS) (8 × 8 mm, HotAxios; Boston Scientific, Marlborough, Mass) was performed from a long-scope position using a free-hand plus preloaded guidewire technique.
The cautery-enabled catheter was advanced less than 1 finger’s width at too perpendicular an angle, hitting the opposite CBD wall. The guidewire could not be inserted deeply, making a loop at the level of the CBD’s access. Deployment of both flanges appeared to be correct, but an EUS image detected a partial malposition of the internal flange. Attempts at advancing the guidewire in an upward/downward direction (failed rendezvous [RV] approach) were unsuccessful, and the LAMS was removed.
Because the CBD was still dilated, a second attempt at EUS-guided CDS using a smaller EC-LAMS (6 × 8 mm, HotAxios) was made. However, this technically failed because of a considerable amount of bile between the CBD and duodenal wall. An EUS-guided RV as an emergent rescue was performed using a 19-gauge, 0.025-inch guidewire. This maneuver was technically demanding because of the small CBD diameter, but it was possible to advance a guidewire through the papilla until it reached the duodenum. Finally, a fully covered metal stent was inserted, sealing the disruption of the CBD wall (Figure 1, Figure 2, Figure 3; Video 1, available online at www.giejournal.org). The patient underwent the procedure well without severe consequences and died 4 months later because of advancement of his illness.
Figure 1.
A, Failed EUS-guided choledochoduodenostomy using a lumen-apposing metal stent with an electrocautery-enhanced delivery system (8 × 8 mm, HotAxios) and a free-hand plus preloaded guidewire technique. The common bile duct was barely dilated. B, The cautery-enabled catheter was advanced into the common bile duct, but the guidewire could not be inserted deeply. C, EUS image detected a partial malposition of the internal flange of the lumen-apposing metal stent.
Figure 2.
A second attempt at EUS-guided choledochoduodenostomy using a smaller lumen-apposing metal stent with an electrocautery-enhanced delivery system (6 × 8 mm, HotAxios) technically failed because of a considerable amount of bile between the common bile duct and the duodenal wall. Accumulated bile (asterisk); dislodged distal flange (arrow).
Figure 3.
A, EUS-guided rendezvous as an emergent rescue was performed with an EUS-guided puncture of the common bile duct using a 19-gauge, 0.025-inch guidewire. B, Successful guidewire insertion across the tumor and papilla.
Adverse events after EUS-CDS using EC-LAMS are possible, and a CBD <15 mm has been reported as a risk factor for technical failure.1, 2, 3 Knowledge of endoscopic rescue options (EUS-guided RV, coaxial SEMS) is crucial to resolve potentially serious unplanned events, such as a failed EUS-CDS using a LAMS (Video 1).4
Disclosure
Dr Gornals is a consultant and paid speaker for Boston Scientific. All other authors disclosed no financial relationships.
Footnotes
If you would like to chat with an author of this article, you may contact Dr Gornals at jgornals@bellvitgehospital.cat.
Supplementary data
EUS-guided biliary rendezvous as an emergent rescue after a failed choledochoduodenostomy using a lumen-apposing metal stent.
References
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Associated Data
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Supplementary Materials
EUS-guided biliary rendezvous as an emergent rescue after a failed choledochoduodenostomy using a lumen-apposing metal stent.
EUS-guided biliary rendezvous as an emergent rescue after a failed choledochoduodenostomy using a lumen-apposing metal stent.