Single-session fluoroless endoscopic ultrasound-guided fine-needle aspiration and choledochoduodenostomy with a biliary lumen-apposing stent

 

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A 56-year-old woman with unresectable pancreatic cancer causing obstructive jaundice and anorexia was referred to our unit for tissue diagnosis and biliary drainage before undergoing evaluation by a medical oncologist. Previous endoscopic retrograde cholangiopancreatography (ERCP) to attempt biliary cannulation because of signs of severe tumoral invasion in the papilla area had failed, and biopsy specimens were negative for malignancy.

Endoscopic ultrasound (EUS) revealed a solid tumor of the pancreatic head, signs of vascular and duodenal wall invasion, and severe dilatation of the common bile duct (CBD) of up to 13 mm. During a single session, first EUS-guided fine-needle aspiration (FNA) was done with a 22-gauge needle, and rapid on-site cytopathologic evaluation revealed a malignant diagnosis ([Fig. 1]); second, EUS-guided biliary drainage was performed successfully.

All procedures were carried out under endosonographic guidance alone, without fluoroscopic assistance. The Hot AXIOS System (Xlumena, Mountain View, California, USA) was used to puncture the CBD directly from the duodenal bulb, without needle or guidewire insertion. A specific diabolo-shaped biliary lumen-apposing metal stent (inner diameter 6 mm, length 8 mm) was successfully placed. All four steps of placing the delivery system were done under EUS guidance ([Fig. 2]). Transmural drainage, as a choledochoduodenostomy, was obtained, and a large amount of dark bile drained into the antrum and duodenum. The total duration of the procedure, from insertion to withdrawal of the linear echoendoscope, was 28 minutes.

This case is a good example of the successful development of dedicated devices designed to be used in interventional EUS, in such a way as to reduce procedure time, device exchange, technical steps, and possibly adverse events [1] [2] [3] and at the same time improve the final clinical outcome. As can be seen in [Video 1], this cautery-tipped stent delivery system simplifies technique, making the difficult easy and allowing fluoroless EUS-guided FNA plus a choledocoduodenostomy [4] [5] to be conducted in a single session.

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• References

• 1 Binmoeller KF, Shah J. A novel lumen-apposing stent for transluminal drainage of nonadherent extraintestinal fluid collections. Endoscopy 2011; 43: 337-342
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Gornals JB, De la Serna-Higuera C, Sánchez-Yague A et al. Endosonography-guided drainage of pancreatic fluid collections with a novel lumen-apposing stent. Surg Endosc 2013; 27: 1428-1434
  CrossrefPubMedGoogle Scholar
• 3 Itoi T, Binmoeller KF. EUS-guided choledochoduodenostomy by using a biflanged lumen-apposing metal stent. Gastrointest Endosc 2014; 79: 715
  CrossrefPubMedGoogle Scholar
• 4 Teoh AY, Binmoeller KF, Lau JY. Single-step EUS-guided puncture and delivery of a lumen-apposing stent for gallbladder drainage using a novel cautery-tipped stent delivery system. Gastrointest Endosc 2014; 80: 1171
  CrossrefPubMedGoogle Scholar
• 5 Rimbaş M, Attili F, Larghi A. Single-session EUS-guided FNA and biliary drainage with use of a biflanged lumen apposing stent on an electrocautery enhanced delivery system: one-stop shop for unresectable pancreatic mass with duodenal obstruction. Gastrointest Endosc 2015; Epub 2015 Apr 25. DOI: 10.1016/j.gie.2015.03.1907.
  PubMedGoogle Scholar