Post written by Giuseppe Vanella, MD, from the Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Our video case shares a compelling demonstration of EUS-directed transenteric ERCP (EDEE) in managing complex biliary adverse events in a patient with surgically altered anatomy. An 80-year-old woman with a history of Roux-en-Y hepaticojejunostomy presented with cholangitis secondary to giant hepaticolithiasis (a 40-mm biliary stone above the hepaticojejunostomy). Traditional approaches would have posed significant challenges because of the patient’s altered anatomy.

This video serves as a practical illustration of how innovative endoscopic techniques can effectively manage intricate biliary issues in patients with anatomical challenges. Creating an endoscopic shortcut between 2 distant loops through lumen-apposing metal stents (LAMSs) allows inaccessible points of the GI anatomy to be within reach of the endoscopist once again.

Alternative procedures for this patient would have involved long-term percutaneous biliary drainage with obvious discomfort and no definitive solution to the problem.

Conversely, the patient has benefited from comprehensive endoscopic management. Furthermore, the potential for long-term LAMS indwelling (even with LAMS exchange in the case of ingrowth) theoretically enables repeated reinterventions as clinically needed.

The video showcases the intricate technical steps involved in one of the most challenging EUS procedures. Initially, the endoscopist must navigate hundreds of jejunal loops to identify the correct one. Subsequently, the endoscopist must create a structure targetable by the LAMS, a process that involves accessing and distending a typically virtual loop.

In addition, EUS-guided anastomoses may present hidden pitfalls, and the video displays how to address a misdeployment event through a LAMS-in-LAMS.

Our experience underscores the importance of embracing emerging techniques such as EDEE in managing biliary adverse events in patients with surgically altered anatomy, especially where repeated interventions may be anticipated.

Ultimately, our aim is to stimulate multidisciplinary discussion of this circumstance and establish the role of EDEE among the resources of tertiary referral centers for biliopancreatic diseases. The overarching goal is to reduce the overall invasiveness of treatment and enhance patients’ quality of life.

Lumen-apposing metal stent (LAMS) misdeployment. Through the LAMS lumen, the peritoneum (blue asterisk) and the biliary loop with enterotomy (red arrow) were clearly visible, identifying a type II LAMS misdeployment.

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