Endoscopic ultrasound (EUS)-guided antegrade stenting (AGS) is established as an alternative
interventional technique in patients in whom endoscopic transpapillary stenting has
failed [1]
[2]. Here, we present a patient who underwent EUS-AGS after diathermic dilation with
placement of a self-expandable metal stent (SEMS) for a malignant distal biliary stricture.
A 58-year-old woman with cancer of unknown origin and obstructive jaundice was referred
to our hospital. She had undergone transpapillary stenting using a plastic stent at
another hospital 2 months previously. Esophagogastroduodenoscopy (EGD) to reach the
papilla of Vater was not feasible because of gastric outlet obstruction. Therefore,
we attempted EUS-AGS via the stomach. First the intrahepatic bile duct was punctured
using a 19-gauge needle and an EUS-guided cholangiogram was performed. Following this
a 0.025-inch guidewire was advanced across the stricture alongside the plastic stent
under fluoroscopic guidance ([Fig. 1 a]). Thereafter, we tried to dilate the stricture using a tapered endoscopic retrograde
cholangiopancreatography (ERCP) catheter, but it was not possible to pass the catheter
across the stricture ([Fig. 1 b]).
Fig. 1 Radiographic images showing: a a guidewire that has been advanced into the duodenum across the distal biliary stricture
and the plastic stent that was previously placed via the transpapillary approach;
b the tapered endoscopic retrograde cholangiopancreatography (ERCP) catheter that could
not be advanced across the stricture; c the wire-guided diathermic dilation being performed; d free drainage of contrast after endoscopic ultrasound-guided antegrade wire-guided
diathermic dilation and antegrade placement of a biliary self-expandable metal stent
(SEMS).
We then performed a dilation of the stricture using a 6-Fr wire-guided diathermic
dilator (Cysto-Gastro-Set; Endo-Flex, GmbH, Voerde, Germany) with a blended cut mode
([Fig. 1 c]). Finally, an uncovered SEMS with a fine delivery system (Zilver635; Cook Japan,
Tokyo, Japan) was placed across the stricture alongside the obstructed plastic stent
without any complications ([Fig. 1 d]; [Video 1]).
Endoscopic ultrasound (EUS)-guided antegrade diathermic dilation and stenting for
a severe refractory distal biliary stricture following conventional transpapillary
stenting.
Recently, EUS-AGS using a tapered ERCP catheter and an uncovered SEMS with a fine
delivery system has been reported [3]. We also reported EUS-guided antegrade wire-guided diathermic dilation followed
by SEMS placement for refractory severe benign biliary stricture [4]. To our knowledge, this is the first report of combined EUS-AGS with diathermic
dilation and placement of an uncovered SEMS for a malignant biliary stricture. EUS-guided
antegrade wire-guided diathermic dilation is useful for severe strictures that cannot
be dilated with conventional techniques as well as for the transpapillary approach
[5].
Endoscopy_UCTN_Code_TTT_1AS_2AD
