LAMS TO THE SEMS RESCUE!

Effective endoscopic biliary drainage may be difficult to achieve when the major papilla is inaccessible to the duodenoscope. In such cases, endoscopic ultrasound-guided biliary drainage appears to be a valid alternative to percutaneous transhepatic biliary drainage. Recently, lumen apposing metal stents (LAMS) have been used to achieve internal biliary drainage through the creation of a choledochoduodenostomy. This particular type of stent may reduce the risk of biliary leak and tends to make the procedure simpler and faster.

We present the case of an 80-year-old woman with a Gastric Outlet Obstruction Syndrome caused by a colorectal cancer metastasis located in the distal duodenum. A luminal self-expandable metal stent (SEMS) of 9 cm (Wallstent®) was inserted, with the proximal flange located in D2. The obstructive symptoms resolved but jaundice quickly developed. An abdominal computerized tomography revealed marked dilation of the common bile duct (CBD), probably caused by the metallic stent at the level of the major papilla. An endoscopic retrograde cholangio-pancreatography was then arranged. Anticipating difficulties in accessing the duodenal papilla, an EUS-guided biliary drainage was also planned in advance. As suspected, the metal mesh in the duodenum hindered the duodenoscope progression, precluding any attempt of biliary cannulation. Since the duodenal bulb was free, we decided to perform a choledochoduodenostomy using a 6 × 8 mm LAMS (Hot-Axios®). A therapeutic echoendoscope was inserted to the duodenal bulb, and a 19G needle was used to puncture the dilated CBD and aspirate bile. A 0.035''guide-wire was then passed and the LAMS was deployed following the manufacturer's instructions. After the procedure, jaundice resolved and the patient was able to resume the palliative chemotherapy prescribed.

This case highlights biliary obstruction as an uncommon complication of endoscopic SEMS placement and the video included demonstrates the steps used to sucessfully create a choledocoduodenostomy using a LAMS.