Endoscopic reintervention for stent dislodgement after endoscopic ultrasound-guided choledochoduodenostomy

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has been performed as an alternative drainage technique when endoscopic retrograde cholangiopancreatography (ERCP) fails [1] [2]. This report describes a case of complete dislodgement of a self-expanding metal stent (SEMS) after EUS-CDS that was successfully treated by endoscopic reintervention.

A 91-year-old man presented to us with fever. He had undergone EUS-CDS with insertion of a fully covered SEMS for obstructive jaundice due to duodenal carcinoma 2 months previously ([Fig. 1 a]). Occlusion of the biliary SEMS was suspected because his liver enzymes were elevated; however, abdominal radiographs unexpectedly revealed complete dislodgement of the stent ([Fig. 1 b]).

Fig. 1 Radiographs in a 91-year-old man with duodenal carcinoma showing: a a fully covered self-expanding metal stent (SEMS) after endoscopic ultrasound-guided choledochoduodenostomy, and a duodenal stent; b complete dislodgement of the biliary stent.

During endoscopy, a small hole was found in the second portion of the duodenum, which was confirmed to be a choledochoduodenal fistula by fluoroscopic imaging ([Fig. 2] and [Fig. 3 a]). Subsequently, we opted to perform endoscopic reintervention. A 0.035-inch guidewire (Hydra Jagwire; Boston Scientific Japan, Tokyo, Japan) was inserted into the intrahepatic bile duct through the fistula. A fully covered SEMS (10 mm × 6 cm; X-Suit NIR; Olympus Medical Systems Corp., Tokyo, Japan) was then placed across the fistula without any complications ([Fig. 3 b]; [Video 1]).

Fig. 2 Endoscopic view of the second portion of the duodenum showing bile leaking from a small hole.

Fig. 3 Radiographs showing: a a catheter advanced through the choledochoduodenal fistula; b a fully covered self-expanding metal stent (SEMS) placed across the fistula.

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Endoscopic reintervention with a fully covered self-expanding metal stent (SEMS) being inserted through the choledochoduodenal fistula.

In patients who have undergone EUS-CDS, stent migration can result in bile leakage into the retroperitoneum; if this occurs, percutaneous transhepatic biliary drainage or emergency surgery must be considered [3]. In our patient, formation of a choledochoduodenal fistula prevented biliary peritonitis even though the stent had been dislodged, and closure of the fistula induced obstructive jaundice. A cautious approach is required in such a situation to avoid damaging the fistula during the procedure of endoscopic reintervention.

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• References

• 1 Kawakubo K, Isayama H, Kato H et al. Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 2014; 21: 328-334
• 2 Hamada T, Isayama H, Nakai Y et al. Transmural biliary drainage can be an alternative to transpapillary drainage in patients with an indwelling duodenal stent. Dig Dis Sci 2014; 59: 1931-1938
• 3 Itoi T, Isayama H, Sofuni A et al. Stent selection and tips on placement technique of EUS-guided biliary drainage: transduodenal and transgastric stenting. J Hepatobiliary Sci 2011; 18: 664-672