Endoscopic ultrasound-guided choledochoduodenostomy with pyloric occlusion by proximal flange of electrocautery-enhanced lumen-apposing metal stent: solving a rare adverse event

An 80-year-old woman presented to our emergency room with jaundice, nausea, and vomiting. An abdominal tomography revealed intrahepatic biliary ducts and common bile duct (CBD) dilation because of an inhomogeneous hypoechoic mass of 2 × 1.5 cm in its distal part and an absence of distant metastases. After a multidisciplinary case discussion it was decided to perform an endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) of the mass and drainage of the CBD.

With a linear echoendoscope (GF-UCT 180; Olympus, Tokyo, Japan), we observed an 18 × 20-mm hypoechoic lesion infiltrating the biliary tract responsible for an upstream dilation of the CBD up to 22 mm. A 22-gauge fine-needle-biopsy needle (Acquire Endoscopic Biopsy Device, Boston Scientific, Marlborough, Massachusetts, USA) was used to perform a biopsy with macroscopic on-site evaluation of the specimen [1]. Histology revealed a cholangiocarcinoma.

An endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful. We decided to perform an EUS-guided choledochoduodenostomy using an electrocautery-enhanced lumen-apposing metal stent (LAMS) (8 × 20-mm Hot SPAXUS; Taewoong Medical, Gyeonggi‐do, South Korea) from the duodenal bulb with the intrachannel release of the proximal flange ([Fig. 1]) [2]. An efficient bile flow was immediately observed through the stent. However, the proximal flange was released transpylorically into the stomach, covering the pylorus completely. With a gastroscope with a preloaded smooth cap, we gently pushed the proximal flange through the pylorus into the duodenal bulb, replacing the proximal flange inside the duodenum ([Fig. 2, ] [Video 1]).

Fig. 1 Ultrasonographic view of the lesion. a Hypoechoic lesion infiltrating the biliary tract. b Dilated bile duct. c Endoscopic ultrasound-guided choledochoduodenostomy.

Fig. 2 Endoscopic view of the lumen-apposing metal stent (LAMS). d Transpyloric release of the metal stent into the stomach. e Proximal flange pushed through the pylorus. f The LAMS pushed into the duodenal bulb.

Video 1 Endoscopic ultrasound-guided choledochoduodenostomy with pyloric occlusion by the proximal flange of an electrocautery-enhanced lumen-apposing metal stent: how to solve a rare adverse event.

This is a possible complication that can be encountered during EUS-guided drainage, especially if the proximal flange release is performed inside the operative channel of the scope. A soft electrocautery-enhanced LAMS, such as the Hot SPAXUS [3], allows easy management of this rare adverse event [4] [5].

Endoscopy_UCTN_Code_TTT_1AS_2AG

Publication History

Article published online:
05 July 2022

• References

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