Endoscopic ultrasound-guided jejunoduodenostomy followed by biliary stenting using an ultrathin endoscope

Endoscopic biliary drainage is challenging in patients with left hepatectomy (LH) and extrahepatic bile duct (EHBD) resection, as balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) may not always be feasible, and endoscopic ultrasound (EUS)-guided hepaticogastrostomy is not an option. We describe a case of EUS-guided jejunoduodenostomy (EUS-JDS) followed by biliary stenting in such a patient ([Video 1]).

Endoscopic ultrasound-guided jejunoduodenostomy followed by biliary stenting using an ultrathin endoscope through an endosonographically created route.Video 1

An 82-year-old woman, with LH and EHBD resection for cholangiocarcinoma, developed obstructive jaundice following cancer recurrence near the hepaticojejunostomy anastomosis (HJA). BE-ERCP failed, and we attempted EUS-JDS for biliary access by puncturing the jejunum near the HJA using a 19G needle ([Fig. 1] a). Although the intrahepatic bile duct (IHBD) was visualized with contrast injection from the jejunum, contrast drainage was poor, suggesting a stricture near the HJA. After inserting two guidewires into the jejunum using a double-lumen cannula, the tract was dilated with a 4-mm balloon ([Fig. 1] b). A fully covered metal stent (10 mm × 7 cm) was placed from the jejunum to the duodenum; a 7-Fr double-pigtail plastic stent (10 cm) was inserted through the metal stent to prevent migration [1] ([Fig. 1] c).

Fig. 1 a The jejunum near the hepaticojejunostomy anastomosis punctured using a 19G needle. b The puncture route is dilated with a 4-mm balloon. c Endoscopic ultrasound-guided jejunoduodenostomy performed using a 10-mm fully covered metal stent combined with a 7-Fr double-pigtail plastic stent.

Eight days later, the EUS-JDS stents were removed, and an ultrathin endoscope (GIF-1200N; Olympus,) was advanced into the jejunum via the EUS-JDS route ([Fig. 2] a). The guidewire was inserted into the right IHBD through the HJA stricture ([Fig. 2] b). An 8-mm uncovered metal stent with a 5.4-Fr delivery system (YABUSAME Neo; Kaneka Medical) was placed from B5 to the jejunum, followed by a second one from B8 to the EUS-JDS route [2] ([Fig. 2] c). The patient’s jaundice improved without any adverse events.

Fig. 2 a After the stents placed during endoscopic ultrasound-guided jejunoduodenostomy were removed, no contrast leakage is observed. b A guidewire inserted into the right intrahepatic bile duct using an ultrathin endoscope. c An 8-mm uncovered metal stent with a 5.4-Fr delivery system is placed from B5 to the jejunum, followed by a second stent through the stent mesh from B8 to the endoscopic ultrasound-guided jejunoduodenostomy route.

A lumen-apposing metal stent is useful for EUS-guided digestive tract anastomosis but unavailable in some countries. Our technique provides a viable alternative for biliary drainage in patients with LH and EHBD resection.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Mandai K, Uno K, Yasuda K. Endoscopic ultrasound-guided treatment for malignant afferent loop obstruction after Roux-en-Y reconstruction. DEN Open 2021; 1: e3
• 2 Mandai K, Ogawa T, Yoshimoto T. Bilateral stent-in-stent placement of biliary metal stents with a slim delivery system through an ultraslim endoscope. Endoscopy 2023; 55: E356-E357

Publication History

Article published online:
19 May 2025