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Create a Free AccountProcedures - Endoscopic ultrasound (EUS) - therapeutic
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.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.1Endoscopic ultrasonography-guided rendezvous technique for removal of a long biliary ascariasis: a challenging case
Biliary ascariasis is a well-known entity in tropical countries.1 ERCP is generally successful in removing them if they are causing cholangitis or obstruction.2 However, in the presence of anatomic distortion, an EUS-guided approach may be needed. To the best of our knowledge, this is the first reported case of the EUS-guided rendezvous technique being used to remove biliary ascaris.EUS-guided biliary rendezvous as an emergent rescue after failed choledochoduodenostomy using a lumen-apposing metal stent
A 60-year-old man with pancreatic cancer and liver metastases who had been referred previously for biliary drainage was recommended palliative oncologic treatment. After a failed transpapillary attempt via ERCP, same-session EUS-guided biliary drainage was chosen. On EUS examination, a minimally dilated common bile duct (CBD) up to 9 mm was identified from the duodenal bulb. An EUS-guided choledochoduodenostomy (CDS) using a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EC-LAMS) (8 × 8 mm, HotAxios; Boston Scientific, Marlborough, Mass) was performed from a long-scope position using a free-hand plus preloaded guidewire technique.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.Combined bridging and antegrade stent placement during transmural treatment for malignant hilar biliary obstruction in a patient with surgically altered anatomy
Recently, bilateral biliary drainage has been considered as the recommended approach for malignant hilar biliary obstruction (MHBO).1 Patients with surgically altered anatomy (SAA) usually represent a challenge for enteroscopy-assisted ERCP (E-ERCP), with its demanding procedure and dedicated technique. This challenge is greatly increased if SAA is combined with MHBO, especially with the limited availability of suitable metal stents for E-ERCP. EUS-guided hepaticogastrostomy (EUS-HGS) has become a feasible alternative approach for this group of patients, allowing bilateral drainage through the bridging technique using an uncovered self-expandable metal stent (SEMS) across the hilar malignant stricture joining the right and left hepatic ducts (RHDs and LHDs, respectively).EUS-guided rendezvous with a steerable access needle in choledocholithiasis
A 60-year-old man who had previously undergone cholecystectomy was seen for a 4-week history of abdominal pain and fever. Investigations revealed leukocytosis (12,000 cell/mm3) and deranged liver function test results (bilirubin 3 mg/dL, serum alkaline phosphatase 360 IU/L). An ultrasound of the abdomen showed a dilated common bile duct (CBD). EUS (UCT-180; Olympus Ltd, Tokyo, Japan) revealed a dilated CBD with multiple calculi without intrahepatic biliary radicle dilation (Fig. 1). Attempts at biliary access during ERCP were unsuccessful because of nonvisualized intradiverticular papilla and duodenal deformity (Fig. 2).EUS-guided drainage of a 20-cm biloma by use of a lumen-apposing metal stent
With the advent of laparoscopic surgery, postoperative bile-duct injuries have become more common over the past several decades.1 Recent studies have suggested that the incidence of bile-duct injury resulting from laparoscopic cholecystectomies ranges from 0.3% to 0.6%.2 Disruption of the biliary ductal anatomy can lead to intra-abdominal leakage of bile and the formation of a biloma. A biloma is defined as “any well-demarcated collection of bile outside the biliary tree.”3 If left untreated, bilomas can lead to significant morbidity and mortality.Management of afferent limb obstruction by use of EUS-guided creation of a jejunojejunostomy and placement of a lumen-apposing metal stent
A 49-year-old woman presented with nausea, vomiting, and abdominal pain. Her medical history consisted of a diverting loop gastrojejunostomy performed because of an obstructing mesenteric desmoid tumor and a recent diagnosis of metastatic adenocarcinoma (Fig. 1). Treatment with different chemotherapy regimens had failed.Endoscopic resection of an unusual ampullary adenoma
A 40-year-old woman with no comorbidities presented with episodic postprandial bilious vomiting of 6 months’ duration and mild abdominal discomfort. Her liver function tests showed normal bilirubin with raised alkaline phosphatase and γ-glutamyltransferase. Abdominal US had shown dilatation of the common bile duct (CBD) and pancreatic duct (PD). She had previously undergone MRCP, which showed diffuse dilatation of the CBD, common hepatic duct, and intrahepatic biliary radicles with smooth tapering at the region of the ampulla, diffuse prominence of the main PD, and ectopic ampulla of Vater.EUS-guided thrombin injection of cystic artery pseudoaneurysm leading to Mirizzi’s syndrome and hemobilia
A 52-year-old man presented with a history of right upper-abdominal pain for 7 days and melena for 3 days. General examination revealed tachycardia, pallor, and icterus. Abdominal examination showed normal results. Laboratory investigations revealed hemoglobin, 7.2 gm (reference, 13-15); alanine aminotransferase, 314 U/L (reference, 0-30); aspartate aminotransferase, 140 U/L (reference, 0-30); serum alkaline phosphatase, 470 U/L (reference, 30-120); and serum bilirubin, 4.6 mg/dL (reference, 0.2-1.2).Crossing the minefield: EUS-guided transesophageal biliary rendezvous in the presence of esophageal varices and ascites
A 75-year-old man presented because of obstructive jaundice with intense itching and significant weight loss. His liver function test result was deranged: bilirubin 22 mg/dL (normal <2 mg/dL), alkaline phosphatase 872 IU/mL (normal <120 IU/mL), along with raised CA19-9 at 10,000 IU/L (normal <37 IU/mL). Contrast-enhanced CT showed a pancreatic head mass, dilatation of the common bile duct (CBD), and intrahepatic biliary radicles, with portal cavernoma and ascites. Gastroscopy revealed large esophageal varices and small gastric varices.
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