A 81-year-old man, who had undergone subtotal gastric resection with Roux-en-Y anastomosis
for gastric adenocarcinoma 2 years earlier, was admitted to our hospital for obstructive
jaundice. Abdominal computed tomography showed a solid mass (30 × 30 mm) at the pancreatic
head, involving the common bile duct and the duodenum and suspicious for portal vein
and mesenteric axis invasion ([Fig. 1]). An endoscopic ultrasonography (EUS)-guided fine needle aspiration was performed
and a diagnosis of metastasis of gastric adenocarcinoma was made.
Fig. 1 Endoscopic ultrasound (EUS) view of pancreatic mass in an 81-year-old man treated
2 years previously for gastric adenocarcinoma by subtotal gastric resection with Roux-en-Y
anastomosis.
Considering the post-surgical anatomy, and in order to obtain endoscopic biliary drainage,
a transgastric intrahepatic EUS-guided approach was attempted. A linear echoendoscope
(GF-UCT140; Olympus, Tokyo, Japan) was used but the intrahepatic bile ducts were not
dilated enough to access them. However the hydropic gallbladder was clearly visible
from the jejunal route.
EUS-guided transluminal gallbladder drainage was therefore performed using a lumen-apposing
metal stent (LAMS) (Hot Axios; Boston Scientific, Natick, Massachusetts, USA) with
a lumen diameter of 10 mm. The gallbladder was first punctured using a 19G access
needle (EchoTip Ultra; Cook Medical, Limerick, Ireland) and a 0.035-inch guidewire
(VisiGlide; Olympus) was left inside to stabilize the echoendoscope position. Subsequently
the stent was introduced into the gallbladder lumen using its cautery tip. Finally
the stent was deployed ([Fig. 2]), with subsequent rapid drainage of the gallbladder into the jejunal lumen ([Fig. 3], and [Video 1]), and nasobiliary drainage was inserted through the stent into the lumen of the
gallbladder ([Fig. 4]). The procedure was successful and the patient’s jaundice rapidly resolved; after
2 weeks total bilirubin had fallen from 11.3 g/dL to 2.5 g/dL).
Fig. 2 The metallic lumen-apposing metal stent (LAMS) stent deployed between gallbladder
and jejunum.
Fig. 3 Biliary drainage of the gallbladder via the jejunal lumen.
Video 1 Endoscopic ultrasound (EUS)-guided transluminal gallbladder drainage performed using
a lumen-apposing metal stent (LAMS).
Fig. 4 Radiological image of the metallic stent with the nasobiliary drainage from the gallbladder
EUS-guided gallbladder drainage using LAMS is safe and effective in the treatment
of acute cholecystitis in high surgical risk candidates [1]
[2]. Our case shows the feasibility of this technique also for obtaining palliative
biliary endoscopic drainage when other routes are precluded.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
