Double-pigtail plastic stent is effective as a rescue therapy after obstruction of choledochoduodenostomy using a lumen-apposing metal stent

Endoscopic ultrasound (EUS)-guided choledochoduodenostomy using a lumen-apposing metal stent (LAMS) is an effective alternative when endoscopic retrograde cholangiopancreatography fails or is impossible [1] [2] [3]. However, although the technique opens up new therapeutic possibilities, it is also associated with new complications, such as obstruction, for which an optimal treatment has not yet been clearly established [4].

We report the case of a 62-year-old patient with metastatic pancreatic adenocarcinoma of the liver exhibiting duodenal invasion. Initial management featured the insertion of a 6-mm LAMS (Hot AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) to allow biliary drainage and a metallic duodenal stent (Wallflex; Boston Scientific) to treat the parietal and ampullary infiltration.

After 1 month, the patient presented with fever, abdominal pain, and jaundice suggestive of a LAMS obstruction. Gastroscopy revealed invasion of the duodenal stent and that the proximal flange of the LAMS was obstructed by food bezoars ([Fig. 1]). After the obstruction was cleared using a lavage pump, we placed a 7-Fr, 10-cm double-pigtail biliary stent (Boston Scientific) inside the LAMS ([Fig. 2, ] [Video 1]).

Fig. 1 Gastroscopy revealed invasion of the duodenal stent and obstruction of the proximal flange of the lumen-apposing metal stent with bezoars.

Fig. 2 Double-pigtail plastic stent in the lumen-apposing metal stent (view from the gastric antrum with transpyloric duodenal stent).

Video 1 Double-pigtail plastic stent placement is an effective rescue therapy after obstruction of a lumen-apposing metal stent placed during choledochoduodenostomy.

Opacification evident at the end of the procedure confirmed permeability of the biliary and duodenal prostheses ([Fig. 3]). Over the following days, the biological jaundice and hyperthermia decreased, allowing resumption of chemotherapy.

Fig. 3 Opacification showing permeability of the biliary and duodenal prostheses.

The addition of a double-pigtail, plastic biliary stent efficiently ensures LAMS patency, especially in cases of duodenal stenosis associated with risks of recurrent obstruction caused by bezoar impaction.

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• References

• 1 Jacques J, Privat J, Pinard F. et al. EUS-guided choledochoduodenostomy by use of electrocautery-enhanced lumen-apposing metal stents: a French multicenter study after implementation of the technique (with video). Gastrointest Endosc 2020; 92: 134-141
• 2 Krishnamoorthi R, Dasari CS, Thoguluva Chandrasekar V. et al. Effectiveness and safety of EUS-guided choledochoduodenostomy using lumen-apposing metal stents (LAMS): a systematic review and meta-analysis. Surg Endosc 2020; 34: 2866-2877
• 3 Jain D, Shah M, Patel U. et al. Endoscopic ultrasound-guided choledocho-enterostomy by using lumen-apposing metal stent in patients with failed endoscopic retrograde cholangiopancreatography: a literature review. Digestion 2018; 98: 1-10
• 4 Fugazza A, Gabbiadini R, Colombo M. et al. Self-expandable metal stent placement as a rescue procedure for lumen-apposing metal stent misdeployment in biliary drainage. Endoscopy 2020; 52: E430-E431