Endoscopic ultrasound (EUS)-guided drainage procedures are becoming increasingly widespread
in clinical practice, even though they are technically challenging and require a substantial
learning curve. In vivo swine biliary dilatation models for training have been described;
however, they provide erratic biliary dilatation and can also be technically cumbersome
[1 – 5]. We describe EUS-guided gallbladder drainage with a lumen-apposing metal stent
(LAMS) in a novel swine biliary dilatation model.
A 30-kg minipig underwent endoscopic retrograde cholangiography and temperature-controlled
endobiliary radiofrequency ablation (EB-RFA) of the distal common bile duct (CBD)
with a dedicated RFA system (ELRA, STARmed) ([Video 1]). The ablation consisted of 10 W of power delivered via an endobiliary catheter-electrode,
with a temperature sensor at a target temperature of 80 °C, for two rounds of 90 seconds.
After 11 days, the pig was re-examined with a linear EUS scope, which revealed dilatation
of both the intrahepatic and extrahepatic biliary ducts, including the gallbladder.
At the distal third of the CBD, an RFA-induced hyperechoic lesion was detected ([Fig. 1]).
Video 1 Video showing endoscopic ultrasound-guided biliary drainage with a lumen-apposing
metal stent in a novel swine biliary dilatation model obtained with a temperature-controlled
endobiliary radiofrequency ablation system.
Fig. 1 Endoscopic ultrasound images in a minipig model showing: a the normal common bile duct (CBD) and portal vein (PV) at the hepatic hilum viewed
from the stomach before radiofrequency ablation (RFA) of the distal CBD; b the distal CBD viewed from the stomach following RFA with evidence of dilatation
of the CBD and intrahepatic biliary ducts (*); c the RFA-induced hyperechoic lesion (arrows) in the distal CBD seen from the bulb;
d the distal flange of the lumen-apposing metal stent, seen from the gastric antrum
and correctly deployed in the distended gallbladder (**).
The distended gallbladder was accessed from the gastric antrum with a 19G needle (Expect,
Boston Scientific). A 0.025-inch guidewire (VisiGlide 2, Olympus) was then inserted
through the needle and coiled into the gallbladder. After a cholecystogastric fistula
had been created using a wire-guided needle knife (MicroKnife, Boston Scientific),
the tract was dilated with a 6-mm balloon (Hurricane, Boston Scientific). Finally,
a 10 × 20-mm LAMS (Spaxus, Taewoong) was placed under combined EUS, fluoroscopic,
and endoscopic guidance ([Fig. 2]).
Fig. 2 Endoscopic view showing the proximal flange of the lumen-apposing metal stent correctly
deployed in the gastric antrum.
Temperature-controlled EB-RFA of the distal CBD proved to be a straightforward, effective,
and novel technique to create a biliary stricture with subsequent massive upstream
biliary dilatation. EUS-guided gallbladder drainage with a LAMS was feasible in this
model, which is theoretically suitable also for other EUS-guided biliary interventions.
Furthermore, the swine model provides excellent haptic feedback and suitable levels
of realism in comparison to procedures undertaken in humans.
Endoscopy_UCTN_Code_TTT_1AU_2AB
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
