Endoscopic ultrasound-guided one-step antegrade metal stent placement with an ultra-slim introducer for preoperative biliary drainage

A 55-year-old-female suffered from advanced obstructive jaundice due to resecetable pancreatic cancer ([Fig. 1]). Preoperative biliary drainage via endoscopic retrograde cholangiopancreatography (ERCP) was attempted but unsuccessful due to duodenal obstruction. We then attempted endoscopic ultrasound-guided antegrade stenting using a novel uncovered self-expandable metal stent (SEMS) with an ultra-slim 5.4-Fr introducer and an ultra-tapered stiff tip (YABUSAME; Kaneka Medix, Osaka, Japan) ([Fig. 2]) after placement of a duodenal stent ([Video 1]). B2 was punctured with a 19-gauge needle via the stomach followed by contrast injection to depict the biliary tree ([Fig. 3 a]). Then, a 0.025-inch angle-tip guidewire (INAZUMA; Kaneka Medix) was successfully manipulated antegrade into the duodenum through the stricture. Just after a removal of the needle, an introducer of a YABUSAME (10 × 60 mm) was inserted into the bile duct without any tract dilation and easily passed through the stricture ([Fig. 3 b]). Finally, the stent was deployed ([Fig. 3 c]). No adverse events had occurred for two weeks until surgery.

Fig. 1 A coronal image of contrast-enhanced computed tomography showed a dilated common bile duct due to pancreatic head cancer (arrow).

Fig. 2 A novel uncovered self-expandable metal stent with an ultra-slim 5.4-Fr introducer and an ultra-tapered stiff tip.

Video 1 Endoscopic ultrasound-guided one-step antegrade metal stent placement with an ultra-slim introducer.

Fig. 3 Fluoroscopic views of endoscopic ultrasound-guided one-step antegrade stenting. a Cholangiogram after the puncture of B2 via the stomach depicted the dilated intrahepatic bile ducts and proximal common bile duct. A duodenal stent was placed in the second part of the duodenum (arrow). b Just after the removal of the needle leaving a guidewire in the duodenum, an introducer of an uncovered self-expandable metal stent was inserted into the duodenum over the guidewire. c The stent (10 × 60 mm) was deployed across the stricture.

EUS-guided biliary drainage includes bilioenterostomy, the rendezvous technique, and antegrade stenting. In preoperative biliary drainage, endoscopic ultrasound-guided bilioenterostomy seems unfavorable because the influence of a bilioenteric fistula on surgery is unknown [1]. Although the EUS-guided rendezvous technique and antegrade stenting do not form a fistula, both have pros and cons. In the rendezvous technique, tract dilation is usually unnecessary, but complicated steps including scope exchange, grabbing and pulling the guidewire, and cannulation are required. EUS-guided antegrade stenting is a simpler method; however, tract dilation with a dilator [2] or catheter [3] prior to insertion of a SEMS introducer is usually required and that increases a risk of the bile leak. In antegrade stenting, this novel introducer is likely to allow a SEMS to be placed just after needle removal and the bile leak and procedural time to be decreased. This method could be a useful alternative after failed ERCP in preoperative biliary drainage.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Isayama H, Nakai Y, Itoi T. et al. Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018. J Hepatobiliary Pancreat Sci 2019; 26: 249-269 DOI: 10.1002/jhbp.631.
• 2 Iwashita T, Nakai Y, Hara K. et al. Endoscopic ultrasound-guided antegrade treatment of bile duct stone in patients with surgically altered anatomy: a multicenter retrospective cohort study. J Hepatobiliary Pancreat Sci 2016; 23: 227-233 DOI: 10.1002/jhbp.329.
• 3 Kawakami H, Kubota Y. Endoscopic ultrasonography-guided antegrade stenting combined with hepaticogastrostomy/hepaticojejunostomy using ultraslim instruments. Endoscopy 2017; 49: E88-E89 DOI: 10.1055/s-0043-1012.

Publication History

Article published online:
02 July 2021