EUS-guided choledochoduodenostomy using a lumen-apposing metal stent through indwelling enteral stents for malignant biliary obstruction.

Dear Editor, An 85-year-old male with duodenal obstruction due to unresectable pancreatic cancer was treated with a self-expandable metal stent (SEMS) placement after informed consent was obtained. The stent migrated proximally so a second coaxial stent placement was performed. Two months later, the patient developed acute cholangitis. A computed tomography scan showed distal biliary obstruction and retrograde dilatation of the bile duct. With a gastroscope, the patency of the coaxial duodenal SEMS was confirmed. ERCP failed due to the duodenal papilla could not be visually recognized. EUS revealed a 17-mm dilated bile duct so a EUS-guided choledochoduodenostomy (EUS-CDS) through the SEMSs was attempted. The bile duct was punctured from the duodenal bulb using a 19-G needle through the mesh of the central segment of SEMS under ultrasonographic view, followed by EUS-guided cholangiography. Thereafter, an 8 mm × 8 mm electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) was placed using the free-hand technique with the intra-channel release. Fluoroscopic and endoscopic views verified correct placement as bile flows into the gastrointestinal tract through the LAMS [Figure 1]. The patient was discharged uneventfully 3 days later. After 3 months, he died for disease progression.Figure 1: EUS-guided choledochoduodenostomy through coaxial self-expandable metal stents. (a and b), A EUS and fluoroscopic image showing a 19-G needle into the CBD through the mesh of the coaxial metal stents (green arrows). (c) Radiological image showing an 8 mm × 8 mm LAMS after deployment. (d) Endoscopic image showing the fully opened proximal LAMS flange breaking through enteral stents. Extensive biliary drainage is noted through the LAMS. CBD: common bile duct; LAMS: lumen-apposing metal stentPatients with periampullary malignancies may present biliary obstruction after luminal obstruction treated with an enteral stent.[1] ERCP is technically challenging in patients with an indwelling duodenal stent and fails in two-thirds of patients, even in experienced hands.[2] In these cases, a EUS-guided biliary drainage is an optimal approach.[3] EUS-CDS using EC-LAMS is an effective and safe option with less technical difficulty than EUS-guided hepaticogastrostomy.[4,5] However, data in patients with indwelling duodenal SEMS are scarce and whether the mesh of the stent can interfere to the EC-LAMS placement is unknown. We report a case of a EUS-CDS using EC-LAMS through two indwelling duodenal SEMSs. This procedure seems feasible and safe, although larger studies are necessary to confirm it. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.