Hybrid endoscopic rescue following endoscopic ultrasound-guided choledochoduodenostomy

Abstract

Figures

A CT scan showing biliary obstruction caused by a mass in the pancreatic head, with a previously placed cholecystogastrostomy lumen-apposing metal stent (LAMS) in situ. CT, computed tomography.

An endoscopic ultrasound image showing common bile duct (CBD) dilation caused by the pancreatic head lesion.

An endoscopic view of the duodenal bulb showing the closure of the wall defect resulting from the initial drainage attempt complicated by type 1 lumen-apposing metal stent (LAMS) misdeployment.

Schematic representation of procedural adverse events and their management: a Duodenal wall defect closure after lumen-apposing metal stent (LAMS) misdeployment. b Stent migration during the second attempt, resulting in biliary and duodenal defects. c The hybrid endoscopic rescue procedure using cholangioscopy for recannulation of the biliary fistula and stent repositioning.

Final endoscopic and fluoroscopic images demonstrating successful biliary drainage.

Full text

An 88-year-old man with biliary obstruction caused by a complex cystic lesion in the pancreatic head, considered inoperable due to significant comorbidities, was referred for endoscopic biliary drainage. Following failed endoscopic retrograde cholangiopancreatography, endoscopic ultrasound (EUS)-guided cholecystogastrostomy was performed, as the cystic duct was patent. Two years later, he presented with cholangitis from recurrent biliary obstruction due to disease progression ( Fig. 1 ). EUS revealed common bile duct (CBD) dilation (~14 mm), caused by the pancreatic head lesion ( Fig. 2 ). Left intrahepatic bile duct dilation was minimal, precluding hepaticogastrostomy. Decision was to perform EUS-guided choledochoduodenostomy.

A CT scan showing biliary obstruction caused by a mass in the pancreatic head, with a previously placed cholecystogastrostomy lumen-apposing metal stent (LAMS) in situ. CT, computed tomography.

An endoscopic ultrasound image showing common bile duct (CBD) dilation caused by the pancreatic head lesion.

The first attempt with a 6 × 8 mm electrocautery-tip lumen-apposing metal stent (Axios, Boston Scientific) using the free-hand technique resulted in a type I misdeployment 1 . The stent was removed, and the duodenal wall defect was closed with two through-the-scope clips ( Fig. 3 ). The second attempt involved CBD puncture using a 19G needle (Expect Slimline, Boston Scientific) for cholangiography and duct distension, fistula creation using an 8.5 Fr cystotome (Cysto-Gastro-Set, Endo-Flex), and the placement of the 10 × 60 mm fully covered metal biliary stent (Evolution, Cook Medical); however, the stent migrated distally during deployment ( Fig. 4 ). Despite multiple attempts, CBD re-canulation using guidewire manipulation was not achieved. Using a therapeutic endoscope (Olympus GIF-2TH180), a cholangioscope (SpyGlass DS II, Boston Scientific) was advanced through the fistula into retroperitoneal space, enabling access to the bile duct and stent placement over a guidewire ( Video 1 ). Final endoscopic and fluoroscopic imaging confirmed pneumobilia and adequate bile/contrast drainage ( Fig. 5 ). Patient recovered rapidly, being discharged on post-procedure day 3.

An endoscopic view of the duodenal bulb showing the closure of the wall defect resulting from the initial drainage attempt complicated by type 1 lumen-apposing metal stent (LAMS) misdeployment.

Schematic representation of procedural adverse events and their management: a Duodenal wall defect closure after lumen-apposing metal stent (LAMS) misdeployment. b Stent migration during the second attempt, resulting in biliary and duodenal defects. c The hybrid endoscopic rescue procedure using cholangioscopy for recannulation of the biliary fistula and stent repositioning.

Final endoscopic and fluoroscopic images demonstrating successful biliary drainage.

Cholangioscopy-assisted recannulation of the biliary fistula after stent migration, enabling guidewire reposition and deployment of a fully covered metal stent to restore effective biliary drainage.Video 1

EUS-guided biliary drainage is an effective alternative when transpapillary drainage is not feasible, although adverse events can be significant 2 . To our knowledge, the use of cholangioscopy for biliary fistula salvage after EUS-choledochoduodenostomy has not been previously reported 3 . This hybrid NOTES-based approach may represent a valuable rescue option in such cases.

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