Endoscopic ultrasound (EUS)-guided biliary drainage is an alternative to percutaneous
transhepatic biliary drainage (PTBD) in patients with malignant biliary obstructions
and those for whom endoscopic retrograde cholangiopancreatography (ERCP) fails or
is impossible. Duodenal stenosis attributable to tumor overgrowth is a classic example
of the latter situation. Although increasing evidence indicates that EUS-guided biliary
drainage is superior to PTBD [1 ], only a few expert centers routinely perform the former procedure, which is technically
challenging.
Recently, new lumen-apposing metal stents (LAMS) placed via electrocautery have become
available; these can be used to aid EUS-guided choledochoduodenostomy (EUS-CDS). These
all-in-one devices facilitate fast, safe EUS-CDS without the need for device exchange
[2 ]. Here, we report the case of a 60-year-old man with duodenal and biliary obstructions
secondary to pancreatic head cancer ([Fig. 1 a ]).
Fig. 1 Endoscopic ultrasound (EUS) and endoscopic views of stent placement for duodenal
and biliary obstructions secondary to pancreatic head cancer. a Pancreatic head cancer. b Dilated main bile duct. c Opening of the distal flange of the lumen-apposing metal stent (LAMS). d EUS view of the deployed LAMS. e Endoscopic view of the stent. f Choledochoduodenostomy and duodenal stent.
The dilated bile duct was easily visualized close to the duodenal bulb using an endoscope
placed via the conventional long route ([Fig. 1 b ]). After direct puncture of the bile duct using the electrocautery device (AXIOS
System; Boston Scientific, Marlborough, Massachusetts, USA), the sheath was pushed
toward the opposite wall of the bile duct for correct positioning of the LAMS (6 mm
diameter) ([Fig. 1 c ]). After locking the sheath, the distal flange was opened under EUS guidance using
the dedicated stent deployment hub. The distal flange was deployed, then the sheath
was gently removed until the distal flange became retracted and took a cone shape.
Next, the proximal flange was deployed and the sheath was pushed to allow final stent
deployment ([Fig. 1 d, e ], [Video 1 ]). A classical duodenal stent was then deployed through the tumoral obstruction ([Fig. 1 f ]).
Video 1 Endoscopic ultrasound-guided choledochoduodenstomy with electrocautery-assisted placement
of a lumen-apposing metal stent (AXIOS) and duodenal stent.
Four studies on EUS-CDS using the new device have already been published [2 ]
[3 ]
[4 ]
[5 ]. The technical and clinical success rates are very high. Morbidity seems to be much
less than that associated with classical EUS-guided biliary drainage, probably because
the absence of opacification and device exchange considerably reduces the risks of
biliary leakage and cholangitis. This procedure may become the standard form of EUS-guided
biliary drainage in patients with distal tumoral biliary obstructions in whom ERCP
fails. The procedure is simple and safe, requiring only EUS guidance. No device exchange
is required. The safety features incorporated into the device will render its use
very popular.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a highhttps://mc.manuscriptcentral.com/e-videos
