ENDOSCOPIC ULTRASOUND ASSISTED FLUOROSCOPY-FREE TRANSPAPILLARY BILIARY DRAINAGE IN PREGNANCY

Background:
Two main reasons for a failed EUS- guided hepaticogastrostomy (EUS-HG) are, inability to access the bile ducts due to non-dilated intrahepatic ducts (IHD), and failure of tract dilation due to cirrhosis/ductal scarring or stent passage from misaligned vector forces. We present 5 cases that failed traditional EUS-HG, treated with EUS-rendezvous-HG.
RESULTS: 5 non-surgical patients, median age 52, (3 M) who failed conventional EUS-HG were treated successfully using 3 techniques. There were no adverse events over a median follow up of 28 months. (Tables 1 and 2)
Technique 1: EUS to IR balloon rendezvous. N=3.
Case 1: A 53 year old female with multiple surgeries and a Whipple procedure, presented with cholangitis and leakage around 2 long standing percutaneous biliary drains (PTBD) due to an afferent limb syndrome. EUS-HG into segment 2 failed to resolve the leak around the PTBD (in segment 3) not easily identifiable at EUS despite contrast injection. However, inflating an IR balloon allowed successful access and creation of an EUS-rendezvous-HG.
Technique 2: IR to IR rendezvous followed by endo-IR rendezvous. N=1.
Case 2: A 55 year old male with multiple comorbidities, prior Whipple procedure and R hepatectomy developed a perihepatic abscess from chronic dehiscence of his hepatico-jejunostomy. Having failed every other attempt to close this leak, an attempt was made for EUS-HG to divert bile from the leak site. Conventional EUS-HG failed due to non-dilated ducts as did an attempt to inflate an IR balloon. So, he underwent an IR to IR rendezvous. A peripheral branch of the L IHD closest to the gastric wall was accessed via the drain, dilated with a 4mm balloon, allowing opening of a loop snare. A transhepatic percutaneous needle puncture of this L IHD was then performed through the loop snare with subsequent puncture of the gastric lumen allowing placement of a guidewire and a successful rendezvous-HG.
Technique 3: EUS to Endo rendezvous. N=1.
Case 3: A 36 year old male with prior severe pancreatitis, benign biliary stricture, gastric outlet, and cirrhosis, had undergone a surgical gastrojejunostomy and hepaticoduodenostomy. He presented with recurrent cholangitis from food occluding his bile duct at the hepaticoduodenostomy (just proximal to the duodenal stricture). He had failed double pigtail biliary stents to keep the food out. So, he was taken for an EUS-HG to provide a more proximal diversion of his biliary tree. Although the L IHD was successfully punctured and a guidewire passed downstream, dilation of the tract failed due to dense scarring. However, after a successful rendezvous with the guidewire, we were able to create an EUS Rendezvous-HG in a retrograde fashion.
Conclusion:
When conventional EUS-HG fails, an EUS-rendezvous-HG with IR or oneself could successfully allow internal drainage rather than a long term PTBD.

Bouveret syndrome is a rare complication of cholelithiasis in which gallstone ileus occurs secondary to an acquired cholecysto-enteric fistula. The gallstone may migrate through the fistula and enter the gastrointestinal tract, causing gastric outlet obstruction. Given the rarity of the condition, there are no standardized treatment guidelines for the management of Bouveret syndrome.

We report a case of a 77-year-old male who presented to the emergency department with a 5-day history of gradual onset epigastric pain associated with nausea and vomiting after meals. His laboratory evaluation was significant for leukocytosis without left shift. Liver biochemistries were normal. Abdominal computed tomography (CT) demonstrated a large approximately 5cm calculus impacted in the proximal duodenum with marked gastric distention. The imaging findings confirmed the presence of a cholecysto-duodenal fistula with associated gastric outlet obstruction.

After multidisciplinary discussions involving surgical colleagues and considering patient preference, we proceeded with endoscopic management. During the endoscopy procedure, a large calculus was found wedged in the duodenal bulb immediately distal to the pylorus with near-total obstruction of the duodenal lumen. Extensive electrohydraulic lithotripsy was performed with delivery of over 15,500 pulses over the course of two prolonged procedures, yielding minimal fragmentation of the large stone. The decision was then made to utilize the submucosal dissection knife with electrosurgical energy. In a cautious and systematic method, stone fragmentation was performed by grasping the stone with the knife tip and delivering electrosurgical energy while retracting the knife into a distal attachment fitted onto our endoscope. Great care was undertaken to avoid mucosal contact and resultant bleeding. This approach yielded large stone fragments which were grasped and withdrawn into the stomach using a retrieval net and large-caliber snare.

After stone fragmentation and removal, a large cholesysto-duodenal fistula was identified with additional multiple large, pigmented stones visualized within the remaining gallbladder body. These stones were able to be retrieved into the stomach with a snare. Next, a 7Fr x 12cm double pigtail plastic stent was advanced antegrade into the duodenal lumen where it was deployed successfully. The proximal pigtail was placed within the gallbladder.

Our patient did well following the final procedure with minimal pain. He was subsequently reviewed by the surgical service and underwent laparoscopic cholecystectomy and fistula closure. Our case demonstrates that Bouveret’s syndrome, in particular gallstone fragmentation, was successfully managed utilizing a submucosal dissection knife with electrosurgical energy.Further evaluation is necessary before this approach can be widely accepted.

A 53 year old patient was referred because of a 3.5 cm obstructing submucosal esophageal tumor at the level of the aortic arch. The tumor was partially calcified. An interdisciplinary decision on an attempt of endoscopic removal using the SET submucosal endoscopic tunneling technique was made. The intervention was carried out with bi-hilar ventilation in the thoraco-surgical OR. The tumor originated form the circular muscular layer and could be enucleated using a 1.5 mm ESD flushknife. When an attempt of endoscopic removal via the enterance tract in the cervical esophagus was made the tumor proved to big to enter through the incision and upper esophageal sphincter. As the patient had an esophageal hernia a second caudal tunnel was created form the tumor bed and a second incision at the level of the preacardial esophagus was created. The tumor could then be pushed through the incision and via the hernia to the gastric lumen. The lesion was then cut into six pieces with a snare and removed from the stomach using a Roth net. Histology showed a calcified leiomyoma without maligancy. Both tunnel enterances were closed by standard and OTSC macro clips and two vacuum sponges were placed in to the esophageal lumen to reduce the local infection risk. The further course was uneventful. Sponges and clip matrial was removed and a control after three month is shown with a smooth esophagus. Only a discrete retraction of the mucosa at the level of the distal mucosal incision was found.
Conclusion: The double tunnel technique may be a helpful new strategy for retrieval of submucosal esophageal tumors to big to be removed via the cervical esophageal sphincter during a SET procedure.

Introduction
Pregnancy is associated with increased tendency to form biliary sludge and stones due to effect of estrogen and progesterone. Upto a third of pregnant women develop biliary sludge and about 12%, gallstones. These usually spontaneously resolve after pregnancy. About 1 in 1200 may develop symptomatic choledocholithiasis during pregnancy, necessitating biliary drainage. However, there are major concerns regarding fetal exposure to radiation. Lead shields, beam collimation and limited fluoroscopy use minimises exposure, still the fetus remains at risk of harm. Fluoroscopy free biliary drainage may be attempted, but has its own limitations. There is thus a need for better therapeutic options for biliary drainage during pregnancy.

Case details
We here report a case of a 31 year old primigravida who presented with moderate cholangitis due to biliary obstruction of unclear etiology. Diagnostic echoendoscopy revealed choledocholithiasis. Luminal endoscopic view of the echoendoscope showed a bulky papilla with orifice at an angle convenient for cannulation. We performed a biliary cannulation in the same setting with the echoendoscope, confirmed biliary placement of sphincterotome on endosonographic view at the same station, and placed a biliary stent. We then confirmed the proper placement of biliary stent crossing the obstructive calculi on the endosonographic view. The entire procedure (diagnosis of etiology, biliary drainage, and confirmation of proper stent placement) was completed in a single setting with the echoendoscope, without the use of fluoroscopy.

The patient had rapid resolution of symptoms, and continued the remained of her pregnancy uneventfully. She delivered a healthy child. Three months later, she returned for bile duct clearance. Cholangiogram showed large calculi in lower and mid common bile duct, which were not amenable to balloon extraction and could not be captured in a mechanical lithotripsy basket. She is now planned for laser lithotripsy.

Conclusion
Biliary drainage during pregnancy can be a difficult prospect. An echoendoscope can potentially facilitate same-session diagnostic and therapeutic transpapillary biliary drainage, avoiding fluoroscopy use. However, this may be applicable only when papillary morphology is conducive, and operator is aware of the technical challenges. In this video, we demonstrate the potential for a fluoroscopy-free single session diagnostic and therapeutic echoendoscopy for transpapillary biliary drainage in pregnancy.