Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative treatment
for patients with malignant biliary obstruction or those with failed endoscopic retrograde
cholangiopancreatography (ERCP) [1]
[2]
[3]
[4]. Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS), a specific type
of EUS-BD, can cause complications, such as bile peritonitis [5]. Previous studies have reported bile leakage in 2.8% of cases and peritonitis in
1.4% of EUS-CDS procedures [2]. In EUS-guided hepaticogastrostomy, a longer length of the liver parenchyma is associated
with a reduced risk of bile leakage [3]. In contrast, EUS-CDS lacks surrounding organ support, potentially increasing the
risk of peritonitis if bile leakage occurs ([Fig. 1]). We developed a novel technique using balloon compression at the fistula site with
an echoendoscope balloon tip to prevent bile leakage-induced peritonitis ([Video 1]).
Fig. 1 The liver parenchyma surrounding the bile duct prevents bile leakage in endoscopic
ultrasound guided-hepaticogastrostomy (EUS-HGS), whereas endoscopic ultrasound guided-choledochoduodenostomy
(EUS-CDS) has a higher risk of bile leakage because of the absence of surrounding
organ protection.
During endoscopic ultrasound-guided choledochoduodenostomy, balloon compression at
the fistula site using the echoendoscope tip before stent placement may prevent bile
leakage-associated complications.Video 1
A 70-year-old woman presented with pancreatic cancer-caused obstructive jaundice.
Pre-procedural computed tomography (CT) revealed a dilated common bile duct ([Fig. 2]). ERCP was unsuccessful because of tumor invasion of the papilla. Therefore, EUS-CDS
was performed as an alternative intervention. Using an echoendoscope (GF-UCT260; Olympus
Medical Systems), the dilated common bile duct was visualized from the duodenal bulb.
An EZ Shot 3 Plus 19G needle (Olympus Medical Systems) was used for puncture, and
a 0.025-inch guidewire was successfully inserted. The puncture site was subsequently
dilated to 4 mm using REN (Kaneka Medix Corporation).
Fig. 2 Pre-procedural computed tomography scan demonstrating a dilated common bile duct (yellow
arrowhead).
Following fistula dilation, to prevent potential bile leakage, the balloon at the
tip of the echoendoscope was inflated to compress the puncture site before metal stent
insertion ([Fig. 3]). Subsequently, a self-expandable metallic stent (Niti-S EUS-BD system; Century
Medical) was placed. Post-procedural CT confirmed the absence of bile leakage ([Fig. 4]). Fistula site compression using the echoendoscope balloon tip after fistula dilation
and before metal stent placement may reduce bile leakage complications in EUS-CDS.
Endoscopy_UCTN_Code_TTT_1AS_2AG
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
Fig. 3
a Endoscopic image demonstrating the inflated balloon tip (yellow asterisk) compressing
the fistula site (yellow arrowhead) following dilation. b Schematic representation of the balloon compression technique demonstrating the spatial
relationship between the echoendoscope, balloon tip, and fistula. c Cholangiography demonstrating bile duct compression using a balloon tip.
Fig. 4 Post-procedure computed tomography scan demonstrating a properly positioned self-expandable
metallic stent (yellow arrowhead) without any bile leakage.
