Combination of endoscopic-ultrasound guided choledochoduodenostomy and gastrojejunostomy resolving combined distal biliary and duodenal obstruction
A 68-year-old man presented with abdominal pain, jaundice, and weight loss for 1 month. Abdominal computed tomography revealed a periampullary mass measuring 3.5 × 3.5 × 3.2 cm with dilated bile duct ([Fig. 1]).
An endoscopic retrograde cholangiopancreatography (ERCP) procedure was not possible owing to a large friable ampullary mass causing supra-ampullary duodenal obstruction ([Fig. 2]). An endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was consequently performed ([Video 1]) with a linear echoendoscope (GF-UCT180; Olympus, Aizu, Japan). A dilated distal common bile duct (CBD) from an ampullary was shown ([Fig. 3]). A 19-gauge endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) needle (Echotip Ultra; Cook Medical Ltd., Limerick, Ireland) with an angled 0.025-inch guidewire (Visiglide 2, Olympus) was used for puncturing. A 6-Fr cystotome (Endo-Flex, Voerde, Germany) and a 4-mm balloon dilatation catheter (Hurricane RX; Boston Scientific, Cork, Ireland) were used for dilation. An 8 × 12-mm lumen-apposing metal stent (LAMS) (Niti-S Spaxus; Taewoong Medical Co., Ilsan, Korea) was successfully placed transduodenally into the distal CBD ([Fig. 4]). Subsequently, an EUS-guided gastrojejunostomy was performed. A 10-Fr nasobiliary catheter (Flexima; Boston Scientific, Marlborough, Massachusetts, USA) was placed into the jejunum to flush a mix of diluted contrast, saline, and methylene blue into the lumen of the jejunum in order to distend the small bowel loop. A 16 × 20-mm LAMS with an electrocautery delivery system (Niti-S Spaxus; Taewoong Medical Co.) was successfully placed transgastrically into the lumen of the jejunum ([Fig. 5]). The patient resumed diet with a decline of bilirubin level at 48 hours after the procedure without adverse events.
Video 1 Endoscopic-ultrasound guided choledochoduodenostomy and gastrojejunostomy resolving combined distal biliary and duodenal obstruction in patient with periampullary cancer.
This case reported the feasibility of a combination of EUS-guided choledochoduodenostomy and EUS-guided gastrojejunostomy to resolve a problem of bile duct and duodenal obstruction type II . Previously, most literature used a combination of EUS-guided biliary drainage and duodenal stents with a technical and clinical success rate of 71.4 % to 100 % and 94.1 % to 100 %, respectively . Future study to compare the efficacy of a combined EUS-guided biliary drainage with EUS-guided gastrojejunostomy versus EUS-guided biliary drainage with a duodenal stent is warranted.
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