CC BY-NC-ND 4.0 · Endosc Int Open 2018; 06(12): E1395-E1397
DOI: 10.1055/a-0735-9254
Case report
Owner and Copyright © Georg Thieme Verlag KG 2018

Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent through an uncovered metal duodenal stent

Adrien Sportes
Hopital Avicenne, Department of Gastroenterology, Bobigny, France
,
Gheoghe Airinei
Hopital Avicenne, Department of Gastroenterology, Bobigny, France
,
Ralph Kamel
Hopital Avicenne, Department of Gastroenterology, Bobigny, France
,
Jean Jacques Raynaud
Hopital Avicenne, Department of Gastroenterology, Bobigny, France
,
Robert Benamouzig
Hopital Avicenne, Department of Gastroenterology, Bobigny, France
› Author Affiliations
Further Information

Corresponding author

Adrien Sportes, MD
Gastroenterology Unit
Hopital Avicenne (AP-HP)
125 Rue de Stalingrad
93000 Bobigny
France   
Fax: +0148955338   

Publication History

submitted 28 March 2018

accepted after revision 30 May 2018

Publication Date:
23 November 2018 (online)

 

Abstract

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) in patients with a preexisting duodenal stent is particularly challenging and has a low success rate. Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) has been increasingly used as an alternative to percutaneous transhepatic biliary drainage after failed ERCP. EUS-guided choledochoduodenostomy (EUS-CD) and EUS-guided hepaticogastrostomy (EUS-HGS) have been reported to have similar efficacity. Recently, a novel dedicated fully-covered lumen-apposing metal stent (LAMS) has been developed for EUS-CD (Hot AXIOS; Boston Scientific, Massachusetts, United States). It seems that this new device decreases the morbidity of EUS-CD. We present a case in which EUS-CD with LAMS through an uncovered metal duodenal stent was used successfully.


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Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with a preexisting duodenal stent is particularly challenging and with low success rate [1]. Recently, a novel, dedicated fully-covered lumen-apposing metal stent (LAMS) has been developed for endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) (Hot AXIOS; Boston Scientific, Massachusetts, United States). We present the case of a successful EUS-CD with LAMS through an uncovered metal duodenal stent.


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Case report

A 56-year-old man with recent abdominal pain and postprandial vomiting underwent a computed tomography (CT) scan, which showed an enlarged tumor of the pancreatic head with duodenal obstruction. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) confirmed the diagnosis of pancreatic adenocarcinoma. At that time, no dilatation of the main bile duct was seen, the liver function test was normal, and no biliary stent was inserted. For a complete duodenal obstruction, an uncovered metal stent duodenal stent was placed.

Two months later, the patient presented with abdominal pain and jaundice. Laboratory tests showed elevated liver function test results: ALT 229 U/L (5 – 45 U/L), AST 181 U/L (5 – 35 U/L), PAL 540 U/L (30 – 110 U/L), γGT 6329 U/L (7 – 50 U/L), Bilirubin 268 μmol/L (0 – 20.5 μmol/L). A computed tomography scan revealed biliary tree dilatation with extrinsic pancreatic compression ([Fig. 1]).

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Fig. 1 Computed tomography scan before endoscopic ultrasound-guided choledochoduodenostomy showed biliary tree dilatation with the duodenal stent in place.

First, ERCP failed to achieve biliary drainage because of an inability to cannulate the papilla due to tumor infiltration. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was not attempted because the left intrahepatic bile ducts were minimally dilated (3 mm). However, the common bile duct (CBD) was largely dilated (20 mm). A Hot AXIOS device with a stent of 8 × 6 mm was advanced through the uncovered metal stent. Pure cut electrocautery current was then applied, allowing the device to reach the CBD. Next, the distal flange was opened ([Fig. 2]) and retracted towards the EUS transducer, and once a biliary and bulbar tissue apposition had been noted, the proximal flange was released ([Fig. 3]). Good drainage of purulent bile was observed ([Video 1]) ([Fig. 4], [Fig. 5]) and no complications occurred during the procedure and 6 months after.

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Fig. 2 Endoscopic ultrasound-guided choledochoduodenostomy with the Hot AXIOS stent and deployment of the distal flange.
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Fig. 3 Endoscopic view of the lumen-apposing metal stent in the duodenum.
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Fig. 4 Radioscopic view of the lumen-apposing metal stent through the duodenal stent.
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Fig. 5 Computed tomography scan showing lumen-apposing metal stent through the duodenal stent.

Video 1  Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent through an uncovered metal duodenal stent


Quality:

Endoscopic ultrasound guided biliary drainage (EUS-BD) has been increasingly used as an alternative to percutaneous transhepatic biliary drainage after failed ERCP [2] [3]. EUS-CD and EUS-HGS have been reported to have similar efficacity [4]. It seems that this new device decreases the morbidity of EUS-CD [5].


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Conclusion

This is the first reported case of EUS-CD through a duodenal metal stent. Failed ERCP after duodenal stent placement is a frequent situation faced by endoscopists during the progression of advanced pancreatic cancer, and ERCP can be easily done using this method.


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Competing interests

None


Corresponding author

Adrien Sportes, MD
Gastroenterology Unit
Hopital Avicenne (AP-HP)
125 Rue de Stalingrad
93000 Bobigny
France   
Fax: +0148955338   


  
Zoom Image
Fig. 1 Computed tomography scan before endoscopic ultrasound-guided choledochoduodenostomy showed biliary tree dilatation with the duodenal stent in place.
Zoom Image
Fig. 2 Endoscopic ultrasound-guided choledochoduodenostomy with the Hot AXIOS stent and deployment of the distal flange.
Zoom Image
Fig. 3 Endoscopic view of the lumen-apposing metal stent in the duodenum.
Zoom Image
Fig. 4 Radioscopic view of the lumen-apposing metal stent through the duodenal stent.
Zoom Image
Fig. 5 Computed tomography scan showing lumen-apposing metal stent through the duodenal stent.