VideoGIE
DISCLOSURE M. Kahaleh is a consultant for Boston Scientific and Xlumina and has done research for Gore, MI Tech, and Pinnacle. He has done research and consulting for Mauna Kea Technologies. No other financial relationships relevant to this article were disclosed.
Fouad Otaki, MD, Prashant Kedia, MD, Nikhil A. Kumta, MD, Michel Kahaleh, MD, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.06.033
EUS-guided biliary drainage with antegrade transpapillary placement of a metal biliary stent
Figure 1. Cholangiogram obtained via endoscopic ultrasound guided transgastric intrahepatic puncture demonstrates a dilated intrahepatic biliary tree. A self expandable metallic stent is deployed over a wire across a distal common bile duct stricture in an antegrade fashion.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
stent also can be placed in an antegrade fashion. We present two cases: (1) A 58-year-old man with a biliary obstruction caused by a 6-cm mass (adenocarcinoma) in the head of the pancreas underwent ERC. Deep biliary access could not be obtained because of a long distal common bile duct stricture. (2) A 40-year-old man with prior Whipple’s surgery for pancreatic adenocarcinoma had recurrence at the hepatojejunostomy. ERC failed because of difficulties with intubation of the afferent limb. In both cases, EUS was performed, and dilated intrahepatic ducts were identified and punctured with a 19-gauge EUS needle, via a transgastric approach. Cholangiography demonstrated a dilated proximal biliary tree with a distal biliary stricture. A wire was advanced through the needle and toward the papilla and/or hepatojejunostomy. The stricture was dilated with a biliary balloon dilator. The duodenal and/or jejunal lumen was opacified with contrast material to direct stent
1010 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org
EUS-guided biliary drainage (EUS-BD) is a minimally invasive technique that provides biliary drainage in patients with malignant biliary obstruction in whom endoscopic retrograde cholangiography (ERC) is not feasible. Intrahepatic or extrahepatic biliary access is obtained, after which transluminal or transpapillary drainage is performed with stent placement. Transpapillary stents can be placed in a retrograde fashion by using the rendezvous technique in which endoscope exchange is required. A transpapillary
VideoGIE
placement. An uncovered self-expandable metal biliary stent was deployed across the stricture and across the papilla and/or hepatojejunostomy in an antegrade fashion. EUS-guided biliary drainage with antegrade transpapillary stent placement achieved efficient biliary drainage and avoided the need for endoscope exchange (Fig. 1; Video 1, available online at www.giejournal.org). DISCLOSURE P. Saxena has received consulting fees from Boston Scientific and research support from Cook Medical. M. Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook
Medical. A. Kalloo is a founding member and equity holder for Apollo Endosurgery. All other authors disclosed no financial relationships relevant to this article. Payal Saxena, MD, Vivek Kumbhari, MD, Mohamad El Zein, MD, Anthony N. Kalloo, MD, Mouen A. Khashab, MD, Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
http://dx.doi.org/10.1016/j.gie.2014.06.038
EUS-guided gastrojejunostomy after failed enteral stenting
Figure 1. Endoscopic view of gastrojejunal anastomosis created with the lumen-apposing metal stent.
An 86-year-old woman with metastatic pancreatic cancer complicated by gastric outlet obstruction with a previously placed enteral stent presented with nausea and vomiting. CT showed a small-bowel obstruction. Endoscopic examination revealed tumor ingrowth This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
within the stent, with distention of the stomach. Given her age and comorbidities, the patient was not a candidate for surgical gastrojejunostomy; therefore, a decision was made to proceed with EUS-guided gastrojejunostomy with use of a lumen-apposing metal stent. A hydrophilic guidewire was advanced distally into the small bowel under fluoroscopic guidance, permitting a 15-mm to 18-mm biliary balloon, inflated with contrast medium, to be passed over the wire. A linear echoendoscope was then advanced into the stomach. Under echosonographic and fluoroscopic visualization, the contrast inflated balloon was Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1011
DISCLOSURE M. Kahaleh is a consultant for Boston Scientific and Xlumina and has done research for Gore, MI Tech, and Pinnacle. He has done research and consulting for Mauna Kea Technologies. No other financial relationships relevant to this article were disclosed.
Fouad Otaki, MD, Prashant Kedia, MD, Nikhil A. Kumta, MD, Michel Kahaleh, MD, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.06.033
EUS-guided biliary drainage with antegrade transpapillary placement of a metal biliary stent
Figure 1. Cholangiogram obtained via endoscopic ultrasound guided transgastric intrahepatic puncture demonstrates a dilated intrahepatic biliary tree. A self expandable metallic stent is deployed over a wire across a distal common bile duct stricture in an antegrade fashion.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
stent also can be placed in an antegrade fashion. We present two cases: (1) A 58-year-old man with a biliary obstruction caused by a 6-cm mass (adenocarcinoma) in the head of the pancreas underwent ERC. Deep biliary access could not be obtained because of a long distal common bile duct stricture. (2) A 40-year-old man with prior Whipple’s surgery for pancreatic adenocarcinoma had recurrence at the hepatojejunostomy. ERC failed because of difficulties with intubation of the afferent limb. In both cases, EUS was performed, and dilated intrahepatic ducts were identified and punctured with a 19-gauge EUS needle, via a transgastric approach. Cholangiography demonstrated a dilated proximal biliary tree with a distal biliary stricture. A wire was advanced through the needle and toward the papilla and/or hepatojejunostomy. The stricture was dilated with a biliary balloon dilator. The duodenal and/or jejunal lumen was opacified with contrast material to direct stent
1010 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org
EUS-guided biliary drainage (EUS-BD) is a minimally invasive technique that provides biliary drainage in patients with malignant biliary obstruction in whom endoscopic retrograde cholangiography (ERC) is not feasible. Intrahepatic or extrahepatic biliary access is obtained, after which transluminal or transpapillary drainage is performed with stent placement. Transpapillary stents can be placed in a retrograde fashion by using the rendezvous technique in which endoscope exchange is required. A transpapillary
VideoGIE
placement. An uncovered self-expandable metal biliary stent was deployed across the stricture and across the papilla and/or hepatojejunostomy in an antegrade fashion. EUS-guided biliary drainage with antegrade transpapillary stent placement achieved efficient biliary drainage and avoided the need for endoscope exchange (Fig. 1; Video 1, available online at www.giejournal.org). DISCLOSURE P. Saxena has received consulting fees from Boston Scientific and research support from Cook Medical. M. Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook
Medical. A. Kalloo is a founding member and equity holder for Apollo Endosurgery. All other authors disclosed no financial relationships relevant to this article. Payal Saxena, MD, Vivek Kumbhari, MD, Mohamad El Zein, MD, Anthony N. Kalloo, MD, Mouen A. Khashab, MD, Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
http://dx.doi.org/10.1016/j.gie.2014.06.038
EUS-guided gastrojejunostomy after failed enteral stenting
Figure 1. Endoscopic view of gastrojejunal anastomosis created with the lumen-apposing metal stent.
An 86-year-old woman with metastatic pancreatic cancer complicated by gastric outlet obstruction with a previously placed enteral stent presented with nausea and vomiting. CT showed a small-bowel obstruction. Endoscopic examination revealed tumor ingrowth This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
within the stent, with distention of the stomach. Given her age and comorbidities, the patient was not a candidate for surgical gastrojejunostomy; therefore, a decision was made to proceed with EUS-guided gastrojejunostomy with use of a lumen-apposing metal stent. A hydrophilic guidewire was advanced distally into the small bowel under fluoroscopic guidance, permitting a 15-mm to 18-mm biliary balloon, inflated with contrast medium, to be passed over the wire. A linear echoendoscope was then advanced into the stomach. Under echosonographic and fluoroscopic visualization, the contrast inflated balloon was Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1011
