EUS-guided biliary rendezvous as an emergent rescue after failed choledochoduodenostomy using a lumen-apposing metal stent

Post written by Joan B. Gornals, MD, PhD, from the Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, University of Barcelona, Catalonia, Spain.

A 60-year-old man with pancreatic cancer and liver metastases who had been referred previously for biliary drainage was recommended palliative treatment. After a failed ERCP, same-session EUS-guided biliary drainage was chosen. A minimally dilated common bile duct (CBD) up to 9 mm was identified from the bulb. An EUS-guided choledochoduodenostomy (CDS) using a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EC-LAMS) (8 x 8 mm, HotAxios) was performed from a long-scope position using a free-hand plus preloaded guidewire technique. The cautery-enabled catheter was advanced less than 1 finger’s width at too perpendicular an angle, hitting the opposite CBD wall. The guidewire could not be inserted deeply, and an EUS image detected a partial malposition of the internal flange. Attempts at advancing the guidewire in an upward/downward direction (failed rendezvous [RV] approach) were unsuccessful, and the LAMS was removed. Because the CBD was still dilated, a second attempt at EUS-guided CDS using a smaller EC-LAMS was made. However, this technically failed because of a considerable amount of bile between the CBD and duodenal wall. An EUS-guided RV as an emergent rescue was performed. This maneuver was technically demanding because of the small CBD diameter, but it was possible to advance a guidewire through the papilla until it reached the duodenum. Finally, a fully covered metal stent was inserted, sealing the disruption of the CBD wall.

Adverse events after EUS-CDS using EC-LAMS are possible, and a CBD <15 mm has been reported as a risk factor for technical failure.

This incident occurred in an experienced unit. Knowledge in EUS-guided rendezvous is crucial to solve dramatic scenarios as a failed EUS-CDS using LAMS.

Knowledge of endoscopic rescue options (EUS-guided Rendezvous, coaxial SEMS) is crucial to resolve potentially serious unplanned events, such as a failed EUS-CDS using a LAMS. A teaching video, with technical helping notes in case of failed EUS-CDS using LAMS, is provided.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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