Endoscopy 2021; 53(06): E223-E225
DOI: 10.1055/a-1244-9651
E-Videos

Endoscopic ultrasound-guided choledochoduodenostomy without fistula dilation using a novel fully covered metallic stent with a 5.9-Fr ultra-thin delivery system

Takehiko Koga
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Susumu Hijioka
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yuya Hisada
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yuta Maruki
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yoshikuni Nagashio
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Takuji Okusaka
1  Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yutaka Saito
2  Department of Endoscopy, Gastrointestinal Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
› Author Affiliations

Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) is a potential procedure for primary drainage in unresectable malignant distal biliary obstruction and can replace endoscopic retrograde cholangiopancreatography. However, adverse events following EUS-CDS are occasionally reported, the most common being bile leak due to fistula dilation [1] [2]. The safety of EUS-CDS without fistula dilation using two types of thin, fully covered self-expandable metallic stents (FCSEMSs) has been previously reported [3] [4] [5]. Here we report a case in which EUS-CDS without fistula dilation was successfully performed using a novel FCSEMS with a 5.9-Fr delivery system (Hanarostent Benefit; M.I.Tech, Seoul, Korea) ([Fig. 1]).

Zoom Image
Fig. 1 Novel fully covered self-expandable metal stent with an ultra-thin delivery system. a The outer sheath of the delivery catheter is size 5.9 Fr. b The expanded stent with a braiding design.

A 62-year-old man who had received chemotherapy for unresectable pancreatic body cancer developed a distal biliary obstruction. Computed tomography revealed a 25-mm mass on the pancreatic body and a dilated common hepatic duct (CHD) ([Fig. 2 a]). We performed EUS-CDS for primary drainage.

Zoom Image
Fig. 2 Image findings before the procedure. a Coronal computed tomographic image revealing a hypovascular mass of the pancreatic body (arrows) and dilated common hepatic duct (CHD) (arrowhead). b Endoscopic ultrasonography image indicating a hypoechoic mass of the pancreatic body (arrows) and dilated CHD (arrowhead).

The dilated CHD was localized using a forward-viewing echoendoscope (TGF-UC260J; Olympus Medical Systems, Tokyo, Japan) from the duodenal bulb ([Fig. 2 b]). First, the CHD was punctured with a 19-gauge needle (EZ Shot 3 Plus; Olympus Medical Systems). Cholangiography revealed a dilated CHD with distal obstruction. Second, a 0.025-inch guidewire (M-Through; ASAHI INTECC Corp., Tokyo, Japan) was inserted into the B4 branch. Fistula dilation was avoided, and the novel FCSEMS (8 mm × 6 cm) was passed through the duodenum and CHD wall smoothly. Finally, the stent was placed in the CHD from the duodenal bulb ([Fig. 3, ] [Fig. 4]; [Video 1]).

Zoom Image
Fig. 3 Endoscopic ultrasonography-guided choledochoduodenostomy without fistula dilation. a The common hepatic duct (CHD) was punctured with a 19-gauge needle. b Cholangiography revealed a dilated CHD with a distal obstruction. c A 0.025-inch guidewire was inserted into the B4 branch, and the fully covered self-expandable metal stent (FCSEMS) was inserted into the CHD without fistula dilation. d The FCSEMS was deployed into the CHD.
Zoom Image
Fig. 4 Image findings after the procedure. a Fluoroscopic image. b Endoscopic image.

Video 1 The video shows an endoscopic ultrasonography-guided choledochoduodenostomy without fistula dilation performed using a novel fully covered self-expandable metal stent with a 5.9-Fr ultra-thin delivery system.


Quality:

No adverse events occurred during or after the procedure.

In previous reports, EUS-CDS without fistula dilation was performed using the FCSEMSs with a 7-Fr or 7.5-Fr delivery system, with 31.6 % – 100 % technical success rate [3] [4] [5]. This is the first report discussing EUS-CDS without fistula dilation using a FCSEMS with a 5.9-Fr delivery system, which is the thinnest ever commercially available delivery system and is capable of simpler and safer EUS-CDS procedures.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos



Publication History

Publication Date:
11 September 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany