Post written by Joan B. Gornals, MD, PhD, from the Hospital Universitari de Bellvitge, Barcelona, Spain.

This is a case of a patient with a recurrent biliary obstruction caused by sump syndrome with dysfunctional endoscopic biliary drainage who underwent EUS-guided choledochoduodenostomy (8- x 8-mm lumen-apposing metal stent [LAMS] + coaxial 7F x 5-cm pigtail) in a potential surgical patient (borderline pancreatic neoplasm). Previous ERCP failed because of ampulla infiltration.

A conversion of transmural to transpapillary drainage was performed using an antegrade trans-LAMS cholangioscopy. The antegrade phase was completed using a therapeutic gastroscope (plus a peroral digital cholangioscope). For retrograde cannulation, a conventional duodenoscope was used.

No adverse events were reported, and clinical improvement on follow-up allowed assessment for potential chemotherapy. No attempt at antegrade stenting through the LAMS was made because of the acute angulation into the lower common bile duct.

The use of a cholangioscope facilitated control of the guidewire in the desired direction and advancement through the tumoral stenosis up to the duodenal lumen. After the scope exchange, a retrograde biliary cannulation was made using monorail technique with a homemade modified 3.9F sphincterotome.

Finally, transpapillary drainage was carried out with a partially covered self-expandable metal stent, placing its proximal cup just distal to the choledochoduodenostomy, allowing removal of the LAMS.

We felt it was important to present this video to show that the conversion of endoscopic transmural biliary drainage (choledochoduodenostomy type) with a LAMS to transpapillary drainage is technically possible and that the use of peroral antegrade cholangioscopy, using the LAMS as entry for rendezvous (or antegrade stenting), is a feasible option.

Several cases of stent dysfunction (eg, food or sludge impaction, tumoral invasion, stent migration, and sump syndrome) have been documented when EUS-guided choledochoduodenostomy is performed using a LAMS. This report offers another endoscopic strategy and enlarges the possibilities of our armamentarium to face it.  

Regards from Barcelona.  

Retrograde biliary cannulation using the monorail technique (homemade modified 3.9F sphincterotome).

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