Endoscopy 2019; 51(04): S24
DOI: 10.1055/s-0039-1681239
ESGE Days 2019 oral presentations
Friday, April 5, 2019 08:30 – 10:30: Video EUS 1 South Hall 1A
Georg Thieme Verlag KG Stuttgart · New York

ENDOSCOPIC MANAGEMENT OF ACCIDENTAL PORTAL VEIN PUNCTURE DURING CHOLEDOCHODUODENOSTOMY USING HOT-AXIOS LUMEN APPOSING METAL STENT

C Mangas-Sanjuan
1   Endoscopy Unit, Hospital General Universitario de Alicante, Alicante, Spain
2   Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
M Bozhychko
1   Endoscopy Unit, Hospital General Universitario de Alicante, Alicante, Spain
2   Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
L Compañy
1   Endoscopy Unit, Hospital General Universitario de Alicante, Alicante, Spain
2   Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
F Antonio Ruiz
1   Endoscopy Unit, Hospital General Universitario de Alicante, Alicante, Spain
2   Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
J Martínez Sempere
1   Endoscopy Unit, Hospital General Universitario de Alicante, Alicante, Spain
2   Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
JA Casellas
1   Endoscopy Unit, Hospital General Universitario de Alicante, Alicante, Spain
2   Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
J Ramón Aparicio
1   Endoscopy Unit, Hospital General Universitario de Alicante, Alicante, Spain
2   Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
› Author Affiliations
Further Information

Publication History

Publication Date:
18 March 2019 (online)

Also available at
 

Introduction:

EUS-guided cholechoduodenostomy is an endoscopic alternative technique to PTHB drainage in patients with malignant distal biliary obstruction when ERCP has failed. However, it is not well stablished how the procedure must be performed when using lumen-apposing metal stents (LAMS) and severe complications associated with the technique may occur. So our aim was to describe the endoscopic management of an accidental portal vein puncture during this procedure.

Endoscopic technique:

We report a clinical case of a 65 year-old woman with obstructive jaundice due to locally advanced unresectable pancreatic adenocarcinoma. After ERCP failure, EUS-guided choledochoduodenostomy was performed. A dilated common bile duct (CBD) (14 mm) was observed so a HOT-Axios catheter using electrocautery wasdirectly inserted into the CBD; after that, a guidewire was introduced trough LAMS catheter. However, after CBD puncture, LAMS catheter and the guidewire were observed inside portal vein. The procedure was continued controlling that the opening of distal flange took place within the CBD. Once the proximal flange was delivered, a severe bleeding was observed trough LAMS. After that, EUS was exchanged by a gastroscope. A guidewire trough LAMS using a sphincterotome was introduced, and the guidewire was passed across the tumor and finally across the papilla. Then, EUS-guided biliary rendezvous technique was performed. A fully-covered self-expandable metal stent was placed to seal disruption between the CBD and portal vein.

Finally, the patient was discharged after 72h without any complication (pain, rebleeding or infection), and bilirubin test normalized after 7 days.

CONCLUSSION:

EUS-guided cholechoduodenostomy using Hot-AXIOS stent placement may be faster than using conventional self-expandable metal or plastic stents, however LAMS-related severe complications may occur. By introducing a guidewire into CBD before LAMS delivery, accidental portal vein puncture may be avoided.