Endoscopic ultrasound-guided choledochoduodenostomy using an innovatively shaped self-expandable metal stent to prevent stent migration

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is now widely performed, not only as an alternative biliary drainage technique when endoscopic retrograde cholangiopancreatography (ERCP) fails, but also as primary drainage for unresectable malignant distal biliary obstruction [1] [2] [3]. The adverse event of stent migration sometimes occurs. In addition, EUS-CDS using a lumen-apposing metal stent (LAMS) has been reported, but if the common bile duct is not very dilated, this technique might be challenging, and misdeployment might occur, especially in nonexpert hands.

A novel tapered self-expandable metal stent (T-SEMS) (K-papilla biliary stent; S&G Biotech, Seoul, Korea) is now available in Japan ([Fig. 1]). The main body of the T-SEMS has a diameter of 10 mm, but the stent is tapered toward the ampulla of Vater area, and at the ampulla of Vater the body diameter of the T-SEMS is 8 mm. With this unique design, an expanding force works toward the hepatic hilar region, and stent dislocation can be prevented. In addition, a wide flare (16 mm in diameter) at the duodenal end prevents stent migration. Furthermore, the absence of flare at the distal end prevents stent-induced ductal change. This stent might be useful to prevent stent dislocation and migration not only related to ERCP, but also to EUS-CDS. Herein, technical tips for EUS-CDS using T-SEMS are provided.

Fig. 1 A novel tapered self-expandable metal stent for biliary drainage (K-papilla biliary stent; S&G Biotech, Seoul, Korea).

An 81-year-old man was admitted to our hospital because of obstructive jaundice caused by cancer of the head of the pancreas. Because of failed biliary cannulation due to tumor invasion into the ampulla of Vater, EUS-CDS was attempted. First, the common bile duct was punctured using a 19-G needle, and the contrast medium was injected ([Fig. 2]). After a 0.025-inch guidewire was deployed within the biliary tract ([Fig. 3]), the common bile duct and duodenal wall were dilated using a 4-mm balloon catheter. Then, the stent delivery system of the T-SEMS was successfully inserted and deployed ([Fig. 4]), without any adverse events. Although the proximal site of the stent was short, to prevent duodenal mucosal injury, no stent migration was observed after 7 days ([Fig. 5], [Video 1]).

Fig. 2 At endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS), the common bile duct is punctured using a 19-G needle and the contrast medium is injected.

Fig. 3 A 0.025-inch guidewire is deployed within the biliary tract.

Fig. 4 The stent delivery system of a novel tapered self-expandable metal stent is successfully inserted and deployed.

Fig. 5 No stent migration is observed after 7 days.

Endoscopic ultrasound-guided choledochoduodenostomy is successfully performed using a novel tapered self-expandable metal stent.Video 1

In conclusion, the T-SEMS might be useful to prevent stent dislocation and migration not only related to ERCP, but also to EUS-CDS, although a comparison study is needed.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Yamazaki H, Yamashita Y, Shimokawa T. et al. Endoscopic ultrasound-guided hepaticogastrostomy versus choledochoduodenostomy for malignant biliary obstruction: a meta-analysis. DEN Open 2023; 4: e274
• 2 Mukai S, Itoi T. Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice. Expert Rev Gastroenterol Hepatol 2023; 17: 1197-1204
• 3 Teoh AYB, Napoleon B, Kunda R. et al. EUS-guided choledocho-duodenostomy using lumen apposing stent versus ERCP with covered metallic stents in patients with unresectable malignant distal biliary obstruction: a multicenter randomized controlled trial (DRA-MBO Trial). Gastroenterology 2023; 165: 473-482.e2

Publication History

Article published online:
08 November 2024