Conventional upper gastrointestinal endoscope retroflexion method for emergent biliary drainage in a patient with esophageal stricture

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is being increasingly used as an alternative treatment to percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction in patients in whom transpapillary drainage fails or for whom this intervention is unsuitable [1] [2] [3]. Although endoscopic ultrasound-guided intrahepatic bile duct fistulation from a reconstructed gastric tube has recently been reported [4], EUS-BD cannot be performed in patients who have problems with ultrasound endoscope passage in the esophagus. Here we report successful performance of emergent endoscopic transpapillary biliary drainage using a conventional upper gastrointestinal endoscope.

A 53-year-old man who underwent esophageal cancer surgery with gastric tube reconstruction presented 15 months later with obstructive jaundice and acute severe cholangitis. Contrast-enhanced computed tomography showed intrahepatic bile duct dilatation due to liver metastases with marked ascites ([Fig. 1]). We opted to perform emergent endoscopic transpapillary biliary drainage. However, a malignant esophageal stricture was unfortunately identified, and a side-viewing duodenoscope (JF-260V; Olympus Medical Systems, Tokyo, Japan) could not pass through the stricture ([Fig. 2]). We therefore attempted biliary drainage using a thinner conventional upper gastrointestinal endoscope (GIF-H290; Olympus Medical Systems, Tokyo, Japan). The scope passed through the stricture, and cannulation of the bile duct was achieved by retroflexing the scope in the second portion of the duodenum ([Fig. 3]). Finally, a 7-Fr, 15-cm straight stent (Flexima; Boston Scientific, Tokyo, Japan) was successfully placed, and adequate biliary drainage was attained ([Fig. 4]; [Video 1]).

Fig. 1 Contrast-enhanced computed tomography showed intrahepatic bile duct dilatation due to liver metastases with marked ascites.

Fig. 2 Endoscopic view of a malignant esophageal stricture.

Fig. 3 Cannulation of the bile duct was achieved by retroflexing the scope in the second portion of the duodenum.

Fig. 4 a Endoscopic retrograde cholangiography was performed in the retroflexed scope position. b A 7-Fr, 15-cm straight stent was successfully placed.

Video 1 Emergent endoscopic biliary stenting was performed using a conventional upper gastrointestinal endoscope.

In this case, EUS-BD was impossible due to the esophageal stricture, and PTBD was inappropriate due to the marked ascites; on the other hand, once the scope passed through the stenosis, transpapillary biliary drainage seemed to be quite reasonable. Transpapillary biliary drainage using a conventional upper gastrointestinal endoscope requires no specialized equipment. This method is worth a try when confronting an esophageal stricture.

Endoscopy_UCTN_Code_TTT_1AR_2AZ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Sharaiha RZ, Khan MA, Kamal F. et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis. Gastrointest Endosc 2017; 85: 904-914
• 2 Liao WC, Angsuwatcharakon P, Isayama H. et al. International consensus recommendations for difficult biliary access. Gastrointest Endosc 2017; 85: 295-304
• 3 Jovani M, Ichkhanian Y, Vosoughi K. et al. EUS-guided biliary drainage for postsurgical anatomy. Endosc Ultrasound 2019; 8: S57-S66
• 4 Maehara K, Hijioka S, Saito Y. Endoscopic ultrasound-guided hepatico-gastrictubestomy for bile duct stent obstruction in a patient with recurrent cancer after esophageal cancer surgery with gastric tube reconstruction. Dig Endosc 2021; 33: 466-467

Publikationsverlauf

Artikel online veröffentlicht:
27. August 2021