A 55-year-old-female suffered from advanced obstructive jaundice due to resecetable
pancreatic cancer ([Fig. 1]). Preoperative biliary drainage via endoscopic retrograde cholangiopancreatography
(ERCP) was attempted but unsuccessful due to duodenal obstruction. We then attempted
endoscopic ultrasound-guided antegrade stenting using a novel uncovered self-expandable
metal stent (SEMS) with an ultra-slim 5.4-Fr introducer and an ultra-tapered stiff
tip (YABUSAME; Kaneka Medix, Osaka, Japan) ([Fig. 2]) after placement of a duodenal stent ([Video 1]). B2 was punctured with a 19-gauge needle via the stomach followed by contrast injection
to depict the biliary tree ([Fig. 3 a]). Then, a 0.025-inch angle-tip guidewire (INAZUMA; Kaneka Medix) was successfully
manipulated antegrade into the duodenum through the stricture. Just after a removal
of the needle, an introducer of a YABUSAME (10 × 60 mm) was inserted into the bile
duct without any tract dilation and easily passed through the stricture ([Fig. 3 b]). Finally, the stent was deployed ([Fig. 3 c]). No adverse events had occurred for two weeks until surgery.
Fig. 1 A coronal image of contrast-enhanced computed tomography showed a dilated common
bile duct due to pancreatic head cancer (arrow).
Fig. 2 A novel uncovered self-expandable metal stent with an ultra-slim 5.4-Fr introducer
and an ultra-tapered stiff tip.
Video 1 Endoscopic ultrasound-guided one-step antegrade metal stent placement with an ultra-slim
introducer.
Fig. 3 Fluoroscopic views of endoscopic ultrasound-guided one-step antegrade stenting. a Cholangiogram after the puncture of B2 via the stomach depicted the dilated intrahepatic
bile ducts and proximal common bile duct. A duodenal stent was placed in the second
part of the duodenum (arrow). b Just after the removal of the needle leaving a guidewire in the duodenum, an introducer
of an uncovered self-expandable metal stent was inserted into the duodenum over the
guidewire. c The stent (10 × 60 mm) was deployed across the stricture.
EUS-guided biliary drainage includes bilioenterostomy, the rendezvous technique, and
antegrade stenting. In preoperative biliary drainage, endoscopic ultrasound-guided
bilioenterostomy seems unfavorable because the influence of a bilioenteric fistula
on surgery is unknown [1]. Although the EUS-guided rendezvous technique and antegrade stenting do not form
a fistula, both have pros and cons. In the rendezvous technique, tract dilation is
usually unnecessary, but complicated steps including scope exchange, grabbing and
pulling the guidewire, and cannulation are required. EUS-guided antegrade stenting
is a simpler method; however, tract dilation with a dilator [2] or catheter [3] prior to insertion of a SEMS introducer is usually required and that increases a
risk of the bile leak. In antegrade stenting, this novel introducer is likely to allow
a SEMS to be placed just after needle removal and the bile leak and procedural time
to be decreased. This method could be a useful alternative after failed ERCP in preoperative
biliary drainage.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
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