Endoscopy 2018; 50(04): S120
DOI: 10.1055/s-0038-1637387
ESGE Days 2018 ePoster Podium presentations
21.04.2018 – EUS interventional: biliopancreatic
Georg Thieme Verlag KG Stuttgart · New York

CAUTERY-TIPPED LUMEN APPOSING METAL STENT PLACEMENT THROUGH THE MESH OF AN INDWELLING DUODENAL SELF-EXPANDING METAL STENT: A NEW WAY TO GET IT DONE (WITH VIDEO)

A Anderloni
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
A Fugazza
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
L Maia
2   Porto Universitary Hospital Centre, Gastroenterology Department, Porto, Portugal
,
F Auriemma
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
E Troncone
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
S Carrara
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
R Maselli
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
PA Galtieri
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
R Semeraro
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
E Ferrara
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
S Attardo
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
L Poliani
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
,
A Repici
1   Humanitas Research Hospital, Digestive Endoscopy Unit, Departement of Gastroenterology, Rozzano (MI), Italy
› Author Affiliations
Further Information

Publication History

Publication Date:
27 March 2018 (online)

 

Combined gastric outlet obstruction (GOO) and malignant biliary obstruction (MBO) are common in periampullary cancer and can occur concomitantly or in sequence. Endoscopic palliation of MBO after the placement of a duodenal self-expanding metal stent (SEMS) can be challenging because of difficult access to the papilla. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) may represent an alternative approach in this context.

We present a case of a 68 year-old woman with an unresectable pancreatic cancer with GOO was successfully palliated with a transpiloric duodenal SEMS placement (Wallflex Duodenal, Boston Scientific, 22 × 60 mm). Two weeks later the patient presented with jaundice (total bilirubin 8 mg/dl) and fever. Despite the papillary orifice was clearly identified immediately distal to the SEMS, deep cannulation failed even after a needle-knife precut attempt.

EUS examination was therefore conducted placing the probe in the duodenal bulb. The presence of tissue ingrowth in the SEMS mesh allowed proper ultrasound evaluation of a dilated (18 mm) common bile duct above a tight distal stricture thus overcoming the possible EUS interference of metallic stent. An EUS-guided choledochoduodenostomy (EUS-CD) with a freestyle fluoroless deployment of a lumen apposing metal stent (LAMS) (Hot-AXIOS, 6 × 8 mm, Boston Scientific, Corp Natick MA, USA) through the mesh of the indwelling duodenal stent was obtained with satisfactory biliary drainage.

Partial resolution of jaundice was observed in the following days with a significant decrease in total bilirubin level (from 8 mg/dl to 2 mg/dl). No complications of the procedure occurred during follow-up (3 weeks).

EUS-CD using a LAMS has been recently reported as an alternative approach in patients with MBO and GOO and failed ERCP. To our knowledge, this is the first case of a LAMS placement through the mesh of an indwelling duodenal SEMS for MBO palliation, showing possible promising further applications.