Endoscopic ultrasound-guided choledochoduodenostomy as a life-saving salvage therapy for post-transplant acute biliary obstruction

Abstract

Figures

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) for post-transplant biliary obstruction. a Endoscopic retrograde cholangiopancreatography (ERCP) failed to place a biliary stent; however, a pancreatic duct stent was placed successfully. b and c EUS-CDS with successful stent deployment. d A naso-biliary catheter was placed in the bile duct through the stent, and fluoroscopy confirmed the absence of leakage.

Full text

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a recognized and effective alternative to conventional retrograde biliary drainage methods, such as endoscopic retrograde cholangiopancreatography (ERCP 1 2 ). While endoscopic ultrasound (EUS) is occasionally employed for diagnosing complications following liver transplantation, the feasibility of EUS-guided interventions for managing post-transplant complications has been documented in only a limited number of case reports 3 4 5 . We report the first case in which endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was successfully utilized as an emergency intervention in a liver transplant recipient with septic shock, following the failure of ERCP.

We report the case of a 61-year-old man who developed cholestatic jaundice and pruritus 1 year after orthotopic liver transplantation. Magnetic resonance cholangiopancreatography revealed a hilar biliary stricture. The patient underwent percutaneous transhepatic cholangiography drainage; however, catheter migration led to inadequate biliary drainage and persistent jaundice. Subsequent ERCP included the placement of a pancreatic duct stent but failed to relieve the biliary obstruction ( Fig. 1 a ). The patient rapidly progressed to septic shock following the procedure. After fluid resuscitation and vasopressor support, EUS-CDS was performed. An 8 mm × 6 mm self-expandable metal stent was deployed between the dilated common bile duct and the duodenal bulb, and an 8.5-Fr naso-biliary catheter was inserted into the bile duct to enable continuous irrigation ( Video 1 , Fig. 1 b–d ).

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) for post-transplant biliary obstruction. a Endoscopic retrograde cholangiopancreatography (ERCP) failed to place a biliary stent; however, a pancreatic duct stent was placed successfully. b and c EUS-CDS with successful stent deployment. d A naso-biliary catheter was placed in the bile duct through the stent, and fluoroscopy confirmed the absence of leakage.

Procedure of endoscopic ultrasound-guided choledochoduodenostomy using a self-expandable metal stent.Video 1

Within 72 hours following the procedure, procalcitonin fell from >100 ng/mL to 12.7 µmol/L, and C-reactive protein decreased from 122.4 to 20.3 mg/L. Haemodynamic stability was restored, and vasopressors were weaned off. The patient was discharged home in stable condition 2 weeks postoperatively.

To the best of our knowledge, this case represents the first reported instance in which EUS-CDS can serve as a life-saving and minimally invasive rescue therapy for septic biliary obstruction when both conventional ERCP and percutaneous approaches have failed in a post-liver transplant patient. This finding may broaden the indications for EUS-BD in post-surgical patients with altered anatomy and life-threatening sepsis, establishing it as a viable emergent therapeutic option.

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