Endoscopic ultrasound-guided choledochoduodenostomy as a life-saving salvage therapy for post-transplant acute biliary obstruction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a recognized and effective alternative to conventional retrograde biliary drainage methods, such as endoscopic retrograde cholangiopancreatography (ERCP [1] [2]). While endoscopic ultrasound (EUS) is occasionally employed for diagnosing complications following liver transplantation, the feasibility of EUS-guided interventions for managing post-transplant complications has been documented in only a limited number of case reports [3] [4] [5]. We report the first case in which endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was successfully utilized as an emergency intervention in a liver transplant recipient with septic shock, following the failure of ERCP.

We report the case of a 61-year-old man who developed cholestatic jaundice and pruritus 1 year after orthotopic liver transplantation. Magnetic resonance cholangiopancreatography revealed a hilar biliary stricture. The patient underwent percutaneous transhepatic cholangiography drainage; however, catheter migration led to inadequate biliary drainage and persistent jaundice. Subsequent ERCP included the placement of a pancreatic duct stent but failed to relieve the biliary obstruction ([Fig. 1] a). The patient rapidly progressed to septic shock following the procedure. After fluid resuscitation and vasopressor support, EUS-CDS was performed. An 8 mm × 6 mm self-expandable metal stent was deployed between the dilated common bile duct and the duodenal bulb, and an 8.5-Fr naso-biliary catheter was inserted into the bile duct to enable continuous irrigation ([Video 1], [Fig. 1] b–d).

Fig. 1 Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) for post-transplant biliary obstruction. a Endoscopic retrograde cholangiopancreatography (ERCP) failed to place a biliary stent; however, a pancreatic duct stent was placed successfully. b and c EUS-CDS with successful stent deployment. d A naso-biliary catheter was placed in the bile duct through the stent, and fluoroscopy confirmed the absence of leakage.

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Procedure of endoscopic ultrasound-guided choledochoduodenostomy using a self-expandable metal stent.Video 1

Within 72 hours following the procedure, procalcitonin fell from >100 ng/mL to 12.7 µmol/L, and C-reactive protein decreased from 122.4 to 20.3 mg/L. Haemodynamic stability was restored, and vasopressors were weaned off. The patient was discharged home in stable condition 2 weeks postoperatively.

To the best of our knowledge, this case represents the first reported instance in which EUS-CDS can serve as a life-saving and minimally invasive rescue therapy for septic biliary obstruction when both conventional ERCP and percutaneous approaches have failed in a post-liver transplant patient. This finding may broaden the indications for EUS-BD in post-surgical patients with altered anatomy and life-threatening sepsis, establishing it as a viable emergent therapeutic option.

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Contributorsʼ Statement

Yiran Song: Writing – original draft, Writing – review & editing. Bixiong Zhang: Data curation, Investigation, Supervision, Validation. Yue Sun: Data curation, Methodology, Validation. Yue Li: Conceptualization, Methodology, Resources, Supervision.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 van der Merwe SW, Van Wanrooij RL, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205
• 2 Khoo S, Do NDT, Kongkam P. Efficacy and safety of EUS biliary drainage in malignant distal and hilar biliary obstruction: A comprehensive review of literature and algorithm. Endosc Ultrasound 2020; 9: 369-379
• 3 Keane MG, Devlin J, Harrison P. et al. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35: 100593
• 4 Leung D. et al. S2870 Successful Use of EUS-Guided Choledochoduodenostomy With LAMS in a Post-Liver Transplant Patient With Recurrent Choledocholithiasis and Cholangitis. 2022; 117: e1871-e1872
• 5 Uchida D. et al. Endoscopic ultrasonography-guided drainage of intra-abdominal fluid collection after liver transplantation: a case series of six patients. J Med Ultrason (2001) 2016; 43: 421-426

Publication History

Article published online:
08 January 2026