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Create a Free AccountProcedures - ERCP/Cholangioscopy
EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy
A 67-year-old man with a history of total gastrectomy followed by Roux-en-Y esophagojejunostomy reconstruction in the setting of gastric adenocarcinoma presented with right-upper-quadrant pain and an abnormal liver function test (LFT) (aspartate aminotransferase 389, alanine aminotransferase 273, alkaline phosphatase 297, total bilirubin 8.70). A liver CT scan was consistent with dilation of the intrahepatic and extrahepatic bile ducts (Figs. 1 and 2; Video 1, available online at www.giejournal.org ).EUS–guided choledochoduodenostomy using a lumen-apposing metal stent in a patient with preexisting duodenal stent and ascites
Endoscopic retrograde cholangiopancreatography in patients with a pre-existing duodenal stent is technically challenging with a low success rate.1 EUS-guided biliary drainage has emerged as a promising technique for patients with malignant biliary obstruction when conventional ERCP fails. Although combined placement of self-expanding metal biliary and duodenal stents can be performed for patients with simultaneous biliary and duodenal obstruction, reports on transduodenal EUS-guided biliary drainage in patients with an existing duodenal metal stent are limited.EUS-directed transenteric ERCP–assisted internalization of a percutaneous biliary drain in Roux-en-Y anatomy
Endoscopic ultrasound–directed transenteric ERCP (EDEE) has recently been described as a safe, effective procedure to obtain biliary access in patients with Roux-en-Y anatomy.1,2 Here, we present a video case report of EDEE-assisted biliary drain internalization in a patient with prior liver transplant and Roux-en-Y hepaticojejunostomy (HJ), presenting with HJ anastomotic stricture (Video 1, available online at www.giejournal.org ).Combined EUS-guided gallbladder drainage with rendezvous ERCP for treatment of concomitant cholecystitis, cholelithiasis, and choledocholithiasis
In recent years, interventional EUS has opened new doors for the management of biliary diseases that would otherwise not be amenable to traditional endoscopic methods. EUS-guided gallbladder drainage (GBD) for cholecystitis represents one such example; studies have demonstrated its safety and efficacy to be equivalent to that of traditional percutaneous drainage and laparoscopic cholecystectomy in patients at high operative risk.1,2 EUS-GBD also offers an alternative biliary drainage modality in cases of malignant biliary obstruction and may even be safe for patients with coagulopathy or on anticoagulation.Endoscopic management of recurrent cholangitis following EUS-guided choledochoduodenostomy
A 74-year-old man who previously underwent a Roux-en-Y gastro-jejunostomy for duodenal stenosis due to an inoperable pancreatic adenocarcinoma was admitted at our institution for obstructive jaundice. Considering the duodenal stenosis, biliary drainage via EUS-guided choledochoduodenostomy was performed using a 6 × 8 mm electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific, Natick, Mass, USA), with subsequent resolution of jaundice (Fig. 1). After 2 months, the patient was readmitted for acute cholangitis: CT scan showed marked dilation of the biliary tracts, with the LAMS in its proper position (Fig. 2).Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-guided gallbladder drainage is safe and feasible
Acute cholecystitis and choledocholithiasis in patients with altered anatomy and major contraindications to surgery represent a challenging clinical scenario.1EUS-guided cholecystoduodenostomy and ERCP in a patient with surgically altered anatomy with a double-balloon endoluminal interventional platform
EUS and ERCP in patients with surgically altered anatomy can be technically challenging. For Roux-en-Y and diverting gastrojejunostomy, achieving deep advancement into the pancreaticobiliary limb for EUS and EUS-guided interventions can be difficult because of the linear echoendoscope’s oblique viewing nature, a longer fixed nonbending portion, and the relatively sharp and stiff tip.1 For ERCP, there are similar challenges with intubating the surgical anastomosis, navigating the variable length of the afferent jejunal limb, and cannulation.Management of combined malignant biliary-duodenal obstruction in Roux-en-Y gastric bypass anatomy with EUS-guided gastrogastrostomy, EUS biliary drainage, and duodenal stent placement
ERCP for patients with Roux-en-Y gastric bypass (RYGB) anatomy is technically challenging. EUS-guided gastrogastrostomy facilitates access to the pancreaticobiliary system and enables us to perform additional procedures.1-5 Here, we describe a case of a patient with RYGB anatomy undergoing EUS-guided gastrogastrostomy followed by EUS-guided fine-needle biopsy (EUS-FNB), EUS-guided biliary drainage, and duodenal stent placement.EUS-guided choledochoduodenostomy creation using a biliary fully covered self-expanding metal stent after maldeployment of lumen-apposing metal stent
A 72-year-old man with stage IV renal cell carcinoma presented with obstructive jaundice secondary to a metastasis in the head of the pancreas. CT imaging demonstrated common bile duct dilation up to 15 mm secondary to a 6-cm pancreatic head mass (Fig. 1). ERCP was attempted but failed because of ampullary effacement from malignant invasion. Because the patient was not a surgical candidate, EUS-guided biliary drainage was attempted.EUS-guided jejunojejunostomy to facilitate ERCP in a patient with unique Roux-en-Y gastric bypass anatomy
Lumen-apposing metal stents (LAMSs), although initially created for draining pancreatic fluid collections, are frequently used in an “off-label” fashion. They have recently gained popularity as a means to facilitate ERCP in patients with surgically altered GI anatomy. We have previously described using LAMSs to create a temporary gastroenterostomy to facilitate ERCP in a patient with duodenal switch anatomy.1 The present case describes the use of a LAMS to enable ERCP in a patient with a history of vertical sleeve gastrectomy converted to a Roux-en-Y gastric bypass.When cholecystostomy tube and transpapillary stents for recurrent cholecystitis fail due to large gallstones: rescue with laser lithotripsy via cholecystoduodenal fistula
Surgical candidates with acute cholecystitis and symptomatic cholelithiasis have conventionally been managed with cholecystectomy. Alternative interventions for nonoperative candidates include percutaneous gallbladder drainage or endoscopic decompression through ERCP and cystic duct stents.1,2 Percutaneous drains have inherent limitations and drain-related issues: pain, bleeding, obstruction, leaking, and dislodgement. Furthermore, they may fail to achieve definitive decompression, especially in cases of large-volume cholelithiasis.EUS-guided gastrojejunal anastomosis to facilitate endoscopic retrograde cholangiography in a patient with a right lobe liver transplant and Roux-en-Y anatomy
Achieving endoscopic biliary access in the setting of altered GI anatomy poses notable technical challenges. Although percutaneous drainage remains a viable alternative, endoscopic approaches are generally preferred by patients because of improvements in quality of life. Roux-en-Y hepaticojejunostomy (RYHJ) biliary reconstruction during liver transplantation is one such example of altered GI anatomy not generally amenable to biliary interventions using conventional endoscopic techniques. We describe a case demonstrating a successful endoscopic approach to achieve biliary access and treat biliary cast syndrome in a patient with a right lobe liver transplant with RYHJ reconstruction.Gastric overtube use to prevent duodenoscope loop formation during EUS-directed transgastric ERCP procedure
A patient with a history of Roux-en-Y gastric bypass surgery in 2003 and cholecystectomy in 2017 was transferred for evaluation of biliary-type abdominal pain and abnormal liver test results. Abdominal US scan demonstrated a dilated bile duct measuring 1.4 cm and choledocholithiasis (Fig. 1). Upper endoscopy confirmed normal Roux-en-Y anatomy, and an EUS-directed transgastric ERCP procedure was planned.Management of adverse events of EUS-directed transgastric ERCP procedure
Accessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period.EUS-guided gastroenterostomy by use of a lumen-apposing metal stent to facilitate ERCP in a patient with duodenal switch anatomy
Lumen-apposing metal stents (LAMSs) have gained popularity in a variety of clinical scenarios. Whereas LAMSs were initially used to drain pancreatic fluid collections, several off-label uses have been developed, including EUS-guided access to facilitate ERCP in patients with surgically altered anatomy. The duodenal switch procedure is a bariatric surgical procedure that induces weight loss by combining a sleeve gastrectomy with an intestinal bypass. This procedure renders the ampulla nearly inaccessible to conventional endoscopic access.Transpapillary nasocystic tube placement to allow gallbladder distention for EUS-guided cholecystoduodenostomy
A 39-year-old woman with a history of Crohn’s disease and multiple bowel resections presented with 2.5 months of right upper-quadrant pain. Transabdominal US demonstrated multiple gallstones and cystic duct obstruction. The surgical consultation noted that the patient’s multiple prior operations significantly increased the risk of morbidity with cholecystectomy. The gastroenterology service was consulted for endoscopic management of chronic cholecystitis and cystic duct obstruction (Video 1, available online at www.VideoGIE.org ).Bilateral metal stent placement: ERCP through EUS-guided gastroenterostomy
A 64-year-old man with a history of gallbladder cancer presented with epigastric pain, nausea, vomiting, and jaundice. He had previously undergone placement of an internal-external biliary tube in the right system and a cholecystostomy tube at an outside hospital. CT showed an extended stomach with a liver mass around the hilum and upstream bile duct dilation, suggestive of gastric outlet obstruction and biliary obstruction (Fig. 1).Lumen-apposing metal stent–related splenic artery erosion: diagnosis and management
Lumen-apposing metal stents (LAMSs) have been shown to be easily placed during endoscopy and appear effective in draining symptomatic peripancreatic fluid collections. Several series have reported late adverse events, especially bleeding, which can be severe and can occur in up to 25% of patients. We report a particularly well-documented bleeding adverse event (Video 1, available online at www.VideoGIE.org ).Lumen-apposing metal stent–assisted electrohydraulic lithotripsy and mechanical lithotripsy for cholelithiasis in a nonsurgical patient
Therapeutic applications of EUS are evolving, and the development of novel devices have made EUS-guided gallbladder drainage a feasible and viable option alternative to nonoperative treatments of choice.Rescue of a delayed spontaneously migrated lumen-apposing metal stent placed to facilitate transluminal ERCP in a patient with acute recurrent pancreatitis and pancreas divisum with Roux-en-Y gastric bypass
ERCP is challenging in patients with Roux-en-Y gastric bypass (RYGB). EUS-directed transgastric ERCP by use of the lumen-apposing metal stent (LAMS) (Axios; Xlumena, Inc, Mountain View, Calif, USA) has been performed in the RYGB population with a high success rate.EUS biliary drainage with a lumen-apposing metal stent through a pre-existing duodenal metal stent
EUS-guided biliary drainage (EUS-BD) is an alternative procedure to percutaneous transhepatic biliary drainage (PTBD) after ERCP failure. Success rates with EUS-BD are estimated to be around 95%, depending on the endoscopist’s experience, and a recent meta-analysis has demonstrated that EUS-BD provides equivalent technical success with lower rates of adverse events in comparison with PTBD.1-4 There are limited data on EUS-BD in patients with an indwelling duodenal stent; only a few articles have suggested that EUS-BD is safe and effective in this patient population.The evolution of EUS-guided cystogastrostomy for pancreatic fluid collections
Endoscopic drainage of pancreatic fluid collections has conventionally been a tedious procedure. Endoscopic drainage may be performed with or without the use of EUS. Conventionally, EUS-guided cystogastrostomy involved EUS-guided needle puncture, repurposed devices, and multiple exchanges over a guidewire. A simple single-device technique can facilitate the procedure.Endoscopic gallbladder drainage in high-risk surgical patients
Nonsurgical candidates with acute cholecystitis are traditionally treated by percutaneous transhepatic or transperitoneal gallbladder drainage that achieves clinical response rates ranging from 56% to 100%.1,2 These approaches, however, may be associated with adverse events, including bleeding and postprocedural infections, in up to 65% of cirrhotic patients. In addition, percutaneous tube placemement may result in patient dissatisfaction, discomfort, and risk of tube dislodgment.3 With the advent of novel endoscopic tools and techniques, internal gallbladder drainage has become an alternative for nonsurgical patients with acute cholecystitis.Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP
Until recently, patients with Roux-en-Y gastric bypass had the options of enteroscopy-assisted or surgery-assisted ERCP.1 However, the use of a lumen-apposing metal stent (LAMS) with EUS to create a transgastric fistula allows for ERCP with a duodenoscope (EUS-directed transgastric ERCP [EDGE]).2 However, dislodgement of the LAMS with advancement of the endoscope can result in a perforation, leading some providers to do this in 2 stages: LAMS placement followed by fistula maturation (7-14 days) and subsequent ERCP.
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