Introduction:
Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) with lumen apposing metal stent (LAMS) is an effective biliary drainage procedure for patients with malignant biliary obstruction following unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). This technique has a high success rate with a lower rate of complications or reintervention. We present a successful salvage technique of a mal-deployed CD LAMS placed through a pre-existing duodenal stent.
Case:
An 83-year-old male with metastatic gastric antral adenocarcinoma status post gastroduodenal stent for gastric outlet obstruction, presented with obstructive jaundice. CT abdomen showed metastatic lymph nodes in the liver hilum with dilated intrahepatic bile ducts and proximal common bile duct (CBD) up to 2 cm. Labs showed direct hyperbilirubinemia, elevated ALT, and ALP levels. ERCP was unsuccessful, thus EUS-CD was attempted. Notably, significant mucosal granularity induced by the indwelling duodenal stent was observed. The dilated CBD was directly punctured with a HOT AXIOS device with no resistance. The distal flange was released under EUS guidance inside the CBD, forming a cone shape to confirm the choledochal-bulbar apposition. Although the proximal flange release resulted in dark-colored bile flow through the duodenal stent, the flange wasn't visible-situated behind the duodenal stent (Figure A-B). A guidewire was immediately inserted through the AXIOS system to secure the stent track. Bile flow gradually stopped as the proximal LAMS flange was embedded in the duodenal bulb wall. Due to uncertain procedural success, contrast was injected through a balloon catheter placed over the guide wire through the LAMS stent (Figure C), showing no leak. An immediate solution to salvage was to place a single flange partially covered metal stent over the guidewire. The stent flange was positioned within the duodenal stent lumen, with uncovered part inside the CBD and the covered part in the duodenal wall via the LAMS. Dark bile flow resumed without pneumoperitoneum on x-ray (Figure D). Liver function improved two days later.
Discussion:
The inadequate deployment of LAMS proximal flange, embedded behind the duodenal stent and in the duodenal wall, can be attributed to two possible factors. Firstly, the placement of the proximal end of the duodenal stent through the pylorus in the gastric lumen hindered adequate contact between the echoendoscope tip and the duodenal bulb wall. Secondly, the duodenal stent induced bulbar mucosal granularity and inflammation. In retrospect, a larger LAMS stent 10X10mm might be more suitable, accommodating the space occupied by the duodenal stent and duodenal wall. The successful use of a single flange partially covered straight biliary metal stent effectively salvaged the embedded LAMS, leading to improved liver function without complications.

Billie Haché

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