Intraductal ultrasonography-directed endoscopic retrograde biliary drainage without fluoroscopy

Common bile duct (CBD) stones may cause septic shock and lead to life-threatening conditions [1]. Endoscopic sphincterotomy (EST) and stone removal is an accepted method for the treatment of CBD stones [2]. EST has the potential to cause bleeding in patients with a bleeding risk. However, endoscopic retrograde biliary drainage (ERBD) can be performed effectively and safely without EST in these patients. ERBD has been performed under fluoroscopy, resulting in a relatively long duration of radiation exposure [3] [4]. Intraductal ultrasound (IDUS) provides real-time cross-sectional imaging within the bile duct. IDUS can be performed without fluoroscopy. Therefore, IDUS-directed ERBD can be used to reduce the time of radiation exposure for both examiners and patients. This report describes IDUS-directed ERBD with a plastic stent without fluoroscopy in patients with a risk of bleeding.

A total of nine IDUS-directed ERBD procedures without fluoroscopy were performed. All procedures were performed using a standard side-viewing duodenoscope (TJF-160F; Olympus, Tokyo, Japan). After cannulation with a 0.035-inch guidewire (Jagwire; Boston Scientific, Natick, Massachusetts, United States), the “bile aspiration” technique was used to indicate bile duct cannulation ([Fig. 1 a]) [5]. A 2.0-mm IDUS probe with a frequency of 20-MHz (UM-G20-29R; Olympus) was advanced over the guidewire into the bile duct. After images of ductal anatomy and lesions had been obtained ([Fig. 1 b]), the insertion length of the IDUS probe, from the papilla of Vater to the lesions, was used to determine the length of plastic stent (Percuflex DUODENAL BEND Biliary Stent; Boston Scientific) that was required. The plastic stent for ERBD was inserted over the guidewire and placed in the correct position after withdrawal of the IDUS probe ([Fig. 1 c]). The location of the ERBD stent was confirmed by plain radiography ([Fig. 1 d]).

Fig. 1 Intraductal ultrasonography (IDUS)-directed endoscopic retrograde biliary drainage (ERBD) without fluoroscopy. a Bile aspiration after biliary cannulation. b IDUS views of a stone in the common bile duct. c Placement of stent for ERBD using IDUS without fluoroscopy. d Plain abdominal radiograph after ERBD insertion.

Successful intubation of the papilla, selective CBD cannulation, and appropriate ERBD were achieved in all patients (9/9, 100 %). No complications were observed in any patient.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests: None

• References

• 1 Lu J, Guo CY, Xu XF et al. Efficacy of intraductal ultrasonography in the diagnosis of non-opaque choledocholith. World J Gastroenterol 2012; 18: 275-278
• 2 Jiang XW, Tang SH, Yang JQ et al. Ultrasound-guided endoscopic biliary drainage: a useful drainage method for biliary decompression in patients with biliary obstructions. Dig Dis Sci 2014; 59: 161-167
• 3 Tsapaki V, Paraskeva KD, Mathou N et al. Patient and endoscopist radiation doses during ERCP procedures. Radiat Prot Dosimetry 2011; 147: 111-113
• 4 Lorenzo-Zuniga V, Alvarez MA, Moreno de Vega V et al. Predictive factors of radiation dose in ERCP: a prospective study in 2 tertiary centers. Surg Laparosc Endosc Percutan Tech 2013; 23: 266-270
• 5 Siegel JH, Rodriquez R, Cohen SA et al. Endoscopic management of cholangitis: critical review of an alternative technique and report of a large series. Am J Gastroenterol 1994; 89: 1142-1146