Endoscopic ultrasound-directed transenteric retrograde cholangiopancreatography using a new slim scope with an operative working channel

A 79-year-old man, with a history of total gastrectomy with esophagojejunostomy on a Roux-en-Y loop for T2N0 adenocarcinoma, was admitted because of abdominal pain and elevated levels on his liver function tests. A computed tomography (CT) scan showed a stone in the common bile duct (CBD). An entero-endoscopic retrograde cholangiopancreatography was attempted with a long pediatric scope using the underwater cap-assisted technique [1], but we failed to reached the papillary region owing to the length of the biliary loop. A 7-Fr endoscopic catheter was advanced through the scope back to the proximal jejunum and left in place to facilitate the next steps [2]. Using a linear operative echoendoscope, we identified the duodenal loop, but were then unable to distend it by injecting contrast and fluid through the endoscopic catheter ([Fig. 1]), so the direct needle-puncture technique was instead used to distend the duodenal loop [3] [4]. Once the target loop was sufficiently distended, an entero-enteric anastomosis was created by placing a 15 × 10-mm lumen-apposing metal stent (LAMS) [5] ([Fig. 2]).

Fig. 1 Endoscopic ultrasound image showing the instillation of contrast and saline with methylene blue via a nasojejunostomy tube at the level of the efferent loop of the anastomosis, with correct positioning being confirmed by the aspiration of methylene blue with a 19G needle.

Fig. 2 Endoscopic image showing the lumen-apposing metal stent (15 × 10 mm) that was placed to create the entero-enteric anastomosis.

The patient was discharged on the following day, then readmitted 2 weeks after the index procedure, when a new slim gastroscope with a 7.9-mm outer diameter and a therapeutic working channel of 3.2 mm was used to reach the papillary region through the LAMS. Using a catheter and hydrophilic guidewire ([Fig. 3]), we were able to selectively cannulate the CBD. Pneumatic dilation of the papilla was performed ([Fig. 4]), and complete clearance of the biliary tract was achieved using an extraction balloon (9–12 mm) ([Fig. 5]; [Video 1]). The LAMS was subsequently removed 1 month later without any adverse events.

Fig. 3 Fluoroscopic image showing cannulation of the bile duct using a forward-viewing scope with a catheter and hydrophilic guidewire.

Fig. 4 Endoscopic image showing pneumatic dilation of the papilla up to 9 mm using an extraction balloon (CRE).

Fig. 5 Fluoroscopic image showing clearance of the bile duct using an extraction balloon (9–12 mm).

Endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography is performed by placing a lumen-apposing metal stent (15 × 10 mm) and using a forward-viewing scope to perform pneumatic dilation of the papilla up to 9 mm and clearance of the bile duct with an extraction balloon.Video 1

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Conflict of Interest

M. Colombo, A. Fugazza, and M. Spadaccini have provided services to Boston Scientific. C. Hassan has provided services to Fujifilm and Medtronic Co. A. Repici has provided services to Fujifilm, Olympus Corp., Medtronic Co., and Boston Scientific. A. De Marco and V. Craviotto declare that they have no conflict of interest.

Acknowledgement

This work was partially supported by “Ricerca corrente” funding from the Italian Ministry of Health to the IRCSS Humanitas Research Hospital.

• References

• 1 Fugazza A, Anderloni A, Paduano D. et al. Underwater cap-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a pilot study. Endoscopy 2021; 53: 927-931
• 2 Spadaccini M, Giacchetto CM, Fiacca M. et al. Endoscopic biliary drainage in surgically altered anatomy. Diagnostics (Basel) 2023; 13: 3623
• 3 Khashab MA. Endoscopic ultrasound-directed transenteric ERCP (EDEE) in patients with postsurgical anatomy – novel but challenging. Endoscopy 2019; 51: 1119-1120
• 4 Trieu JA, Baron TH. EUS-guided gastroenterostomy using direct needle-puncture technique. VideoGIE 2023; 9: 164-168
• 5 Mutignani M, Forti E, Larghi A. et al. Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy. Endoscopy 2019; 5: 1146-1150

Publication History

Article published online:
13 June 2025