Post written by Hiroki Sato, MD, PhD, Hidemasa Kawabata, MD, PhD, and Mikihiro Fujiya, MD, PhD, from the Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan.

We encountered 2 cases of stent migrations and 1 case with repeated cholangitis. In the first 2 cases, the metal stent inserted during the first EUS-guided biliary drainage (EUS-BD) was migrated. Consequently, we punctured its side wall under EUS observation with an EUS-guided FNA needle (19-gauge EZshot 3 Plus; Olympus Medical Systems, Tokyo, Japan).

After we passed through a guidewire, we performed dilator expansion, followed by insertion of a second fully covered metal stent (HANAROSTENT, 10 mm × 10 cm; M.I. Tech) that could protrude from the GI wall. This prevented bile peritonitis and its associated surgical interventions.

As the final configuration resembled a Lambda shape, we named this technique the Lambda stenting technique (Figure).

In the remaining case, although the stent remained in the GI wall, food reflux easily caused recurrent cholangitis. Therefore, we applied the Lambda stenting technique in a similar manner, performing puncture, expansion, and stent insertion under direct visualization.

EUS-BD has become widely used as a biliary drainage technique in recent years. However, dealing with adverse events during EUS-BD is often difficult and can lead to life-threatening adverse events.

Furthermore, patients undergoing EUS-BD are typically at an advanced stage of malignant diseases. In such cases, troubleshooting techniques for issues such as stent migration and recurrent cholangitis are deemed to be of utmost importance.

Other endoscopists can learn from our experience that when adverse events occur, it is crucial to consider prioritizing patient safety and to aim to minimize these events arising from endoscopic procedures.

Please read the main text for a detailed explanation of the techniques, including figures and videos illustrating the procedures. We thank VideoGIE for the opportunity to present this case series.

The Lambda stenting technique involves visualizing the migrated stent under EUS or direct visualization and puncturing it with an EUS-guided FNA needle. After expansion of the punctured site, the stent is delivered. The procedural steps progress from left to right.

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