VideoGIE
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. online at www.giejournal.org). Repeated attempts to cannulate the bile duct were unsuccessful. Initial engagement was possible, but the guidewire could could only be advanced into the pancreatic duct. A pancreatic precut sphincterotomy was performed in the opposite orientation at the 1 o’clock position in an attempt to expose the bile duct. Cannulation of the bile duct was still unsuccessful, so a needle-knife precut was performed in a 1 to 2 o’clock orientation. Cannulation of the bile duct was then achieved, and a biliary sphincterotomy was performed. Cholangiogram confirmed a common hepatic duct stricture with proximal upstream dilation. Brushings of the biliary stricture were performed over a guidewire. A 5F 15 cm single pigtail plastic stent was deployed over a guidewire into the pancreatic duct. A 10 60 mm fully covered, self-expanding metal stent was deployed across the biliary stricture with successful biliary drainage post-deployment. Pathology from the
biliary brushings revealed cholangiocarcinoma. Magnetic resonance angiography showed no vessel involvement and no distant metastases. The patient is currently awaiting surgical resection by the liver transplant surgical team. DISCLOSURE The following author received research support from Gore, MI Tech, Pinnacle, and Maunakea: M. Kahaleh. In addition, the following author disclosed financial relationships relevant to this publication: M. Kahaleh: Consultant for Boston Scientific, Xlumina, and Maunakea. All other authors disclosed no financial relationships relevant to this publication. Amy Tyberg, MD, Taeyoon Lee, MD, Kunal Karia, MD, Supriya Suresh, MD, Dong Choon Kim, MD, Reem Z. Sharaiha, MD, Michel Kahaleh, MD, FASGE, Division of Gastroenterology and Hepatology, Weil Cornell Medical College, Cornell University New York, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.09.062
EUS-guided choledochoduodenostomy with a lumen-apposing metal stent before duodenal stent placement for malignant biliary and duodenal obstruction
Figure 1. A, Endoscopic view of the biflanged, lumen-apposing metal stent. B, Fluoroscopic view of the both the biflanged, lumen-apposing metal stent and the duodenal metal stent.
Treatment of biliary obstruction when the major papilla is inaccessible is challenging. EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) (AXIOS, Xlumena Inc, Mountain View, Calif) either alone or after duodenal stent placement has been reported. We report LAMS placement before duodenal stent placement for malignant biliary and www.giejournal.org
duodenal obstruction (BDO) (Video 1, available online at www.giejournal.org). A 56-year-old man with metastatic cancer involving the liver, duodenum, and colon presented with BDO. ERCP was not possible because of an infiltrating ulcerated, stenotic mass preventing major papilla access. EUS-guided biliary access was performed using a Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1019
VideoGIE
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. transbulbar approach, and the tract was dilated with a 4mm dilating balloon. A biflanged LAMS (inner diameter, 10 mm; length, 10 mm) was placed under EUS and fluoroscopic guidance (Fig. 1A). The duodenal stricture was treated with an enteric metal stent overlapping the LAMS (Fig. 1B). The patient tolerated the procedure with resolution of BDO. EUS-CDS has conventionally been performed using long, straight, metal biliary stents. The dumbbell-shaped LAMS offers an alternative approach with the advantage of maintaining tissue apposition using a low-profile, wide-
lumen stent, which can be placed before placement of a duodenal stent without compromising the CDS.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Brooke R. Glessing, MD, Shawn Mallery, MD, Martin L. Freeman, MD, University of Minnesota, Minneapolis, Minnesota, USA, Madeline D. Newcomb, Cleveland Institute of Art, Cleveland, Ohio, USA, Mustafa A. Arain, MD, University of Minnesota, Minneapolis, Minnesota, USA
http://dx.doi.org/10.1016/j.gie.2014.09.061
Closure of a perforated duodenal ulcer by over-the-scope clip
Figure 1. A, Endoscopic view of duodenal perforation; note the jaws of the clip seen through the cap. B, A twin-grasper is used to grasp one edge of the perforation, followed by the opposite edge (C). D, The edges of the perforation are brought into the cap before clip deployment.
Until recently, endoscopic closure of luminal GI perforations posed a significant challenge. The only accessory equipment available for this purpose was the so-called
through-the-scope clip. However, the ability of these clips to close perforations is greatly limited by the width and depth of the perforation and the degree of required tissue opposition.
1020 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org
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. online at www.giejournal.org). Repeated attempts to cannulate the bile duct were unsuccessful. Initial engagement was possible, but the guidewire could could only be advanced into the pancreatic duct. A pancreatic precut sphincterotomy was performed in the opposite orientation at the 1 o’clock position in an attempt to expose the bile duct. Cannulation of the bile duct was still unsuccessful, so a needle-knife precut was performed in a 1 to 2 o’clock orientation. Cannulation of the bile duct was then achieved, and a biliary sphincterotomy was performed. Cholangiogram confirmed a common hepatic duct stricture with proximal upstream dilation. Brushings of the biliary stricture were performed over a guidewire. A 5F 15 cm single pigtail plastic stent was deployed over a guidewire into the pancreatic duct. A 10 60 mm fully covered, self-expanding metal stent was deployed across the biliary stricture with successful biliary drainage post-deployment. Pathology from the
biliary brushings revealed cholangiocarcinoma. Magnetic resonance angiography showed no vessel involvement and no distant metastases. The patient is currently awaiting surgical resection by the liver transplant surgical team. DISCLOSURE The following author received research support from Gore, MI Tech, Pinnacle, and Maunakea: M. Kahaleh. In addition, the following author disclosed financial relationships relevant to this publication: M. Kahaleh: Consultant for Boston Scientific, Xlumina, and Maunakea. All other authors disclosed no financial relationships relevant to this publication. Amy Tyberg, MD, Taeyoon Lee, MD, Kunal Karia, MD, Supriya Suresh, MD, Dong Choon Kim, MD, Reem Z. Sharaiha, MD, Michel Kahaleh, MD, FASGE, Division of Gastroenterology and Hepatology, Weil Cornell Medical College, Cornell University New York, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.09.062
EUS-guided choledochoduodenostomy with a lumen-apposing metal stent before duodenal stent placement for malignant biliary and duodenal obstruction
Figure 1. A, Endoscopic view of the biflanged, lumen-apposing metal stent. B, Fluoroscopic view of the both the biflanged, lumen-apposing metal stent and the duodenal metal stent.
Treatment of biliary obstruction when the major papilla is inaccessible is challenging. EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) (AXIOS, Xlumena Inc, Mountain View, Calif) either alone or after duodenal stent placement has been reported. We report LAMS placement before duodenal stent placement for malignant biliary and www.giejournal.org
duodenal obstruction (BDO) (Video 1, available online at www.giejournal.org). A 56-year-old man with metastatic cancer involving the liver, duodenum, and colon presented with BDO. ERCP was not possible because of an infiltrating ulcerated, stenotic mass preventing major papilla access. EUS-guided biliary access was performed using a Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1019
VideoGIE
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. transbulbar approach, and the tract was dilated with a 4mm dilating balloon. A biflanged LAMS (inner diameter, 10 mm; length, 10 mm) was placed under EUS and fluoroscopic guidance (Fig. 1A). The duodenal stricture was treated with an enteric metal stent overlapping the LAMS (Fig. 1B). The patient tolerated the procedure with resolution of BDO. EUS-CDS has conventionally been performed using long, straight, metal biliary stents. The dumbbell-shaped LAMS offers an alternative approach with the advantage of maintaining tissue apposition using a low-profile, wide-
lumen stent, which can be placed before placement of a duodenal stent without compromising the CDS.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Brooke R. Glessing, MD, Shawn Mallery, MD, Martin L. Freeman, MD, University of Minnesota, Minneapolis, Minnesota, USA, Madeline D. Newcomb, Cleveland Institute of Art, Cleveland, Ohio, USA, Mustafa A. Arain, MD, University of Minnesota, Minneapolis, Minnesota, USA
http://dx.doi.org/10.1016/j.gie.2014.09.061
Closure of a perforated duodenal ulcer by over-the-scope clip
Figure 1. A, Endoscopic view of duodenal perforation; note the jaws of the clip seen through the cap. B, A twin-grasper is used to grasp one edge of the perforation, followed by the opposite edge (C). D, The edges of the perforation are brought into the cap before clip deployment.
Until recently, endoscopic closure of luminal GI perforations posed a significant challenge. The only accessory equipment available for this purpose was the so-called
through-the-scope clip. However, the ability of these clips to close perforations is greatly limited by the width and depth of the perforation and the degree of required tissue opposition.
1020 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org
