Endosonographically guided gallbladder drainage to treat neoplastic jaundice after Roux-en-Y gastric resection

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.

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• References

• 1 Dollhopf M, Larghi A, Will U. et al. EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device. Gastrointest Endosc 2017; DOI: 10.1016/j.gie.2017.02.027.
• 2 Barbera C, Grande G, Alberghina N. et al. Single-step endoscopic ultrasound-guided fluoroless gallbladder drainage using the Axios lumen-apposing metal stent. Endoscopy 2016; 48 (Suppl. 01) E25