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

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]).

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.

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]).

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.

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.

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.

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Competing interests

The authors declare that they have no conflict of interest.

Acknowledgements

This work was supported in part by The National Cancer Center Research and Development Fund (31-A-13).

• References

• 1 Kawakubo K, Isayama H, Kato H. et al. Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 2014; 21: 328-334
• 2 Wang K, Zhu J, Xing L. et al. Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc 2016; 83: 1218-1227
• 3 Park DH, Lee TH, Paik WH. et al. Feasibility and safety of a novel dedicated device for one-step EUS-guided biliary drainage: a randomized trial. J Gastroenterol Hepatol 2015; 30: 1461-1466
• 4 Itonaga M, Kitano M, Hatamaru K. et al. Endoscopic ultrasound-guided choledochoduodenostomy using a thin stent delivery system in patients with unresectable malignant distal biliary obstruction: a prospective multicenter study. Dig Endosc 2019; 31: 291-298
• 5 Paik WH, Lee TH, Park DH. et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial. Am J Gastroenterol 2018; 113: 987-997

Publication History

Article published online:
11 September 2020