VideoGIE
dilated papillary orifice, and direct cholangioscopy was performed. An electrohydraulic lithotripsy probe progressively fractured the stone until the surgical clip nidus was visualized. The clip was freed and removed by using forceps. After stone retrieval, a 7F, 7-cm plastic biliary stent was placed, and the patient was treated with antibiotics for 5 days. This case describes the successful use of singleballoon enteroscopy to perform direct peroral cholangioscopy in a patient with surgically altered anatomy to
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.
remove a cat’s eye calculus (Video 1, available online at www.giejournal.org). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. None of the editors acted as a reviewer for this article. Ryan Law, DO, Division ogy, Mayo Clinic, H. Baron, MD, FASGE, Hepatology, University of Carolina, USA
of Gastroenterology and HepatolRochester, Minnesota, Todd Division of Gastroenterology and North Carolina, Chapel Hill, North
http://dx.doi.org/10.1016/j.gie.2014.04.031
EUS-guided hepaticojejunostomy combined with antegrade stent placement
Figure 1. A, Successful insertion of the guidewire into the intestine. B, We performed EUS-guided antegrade stent placement by using a Zilver 635 stent (6 cm 10 mm, uncovered, with 6F delivery system).
We describe herein technical tips of EUS-guided hepaticojejunostomy combined with EUS-guided antegrade stent placement by using a fine-gauge delivery system. A 39-year-old woman who had undergone total gastrectomy with a Roux-en-Y procedure developed obstructive jaundice during postoperative chemotherapy. Her carcinoembryonic antigen level was elevated (82 mg/dL; normal, !5 mg/dL). A CT scan showed extrinsic obstruction of 462 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 2 : 2015
the proximal-to-middle common bile duct. We decided to perform EUS-guided hepaticojejunostomy. We punctured the intrahepatic bile duct by using a 19gauge needle from the jejunum, then inserted a 7F tapered ERCP catheter and advanced a guidewire into the intestine across the site of bile duct stenosis (Fig. 1A; Video 1, available online at www.giejournal.org). We inserted a fine-gauge delivery system without dilation of the fistula, www.giejournal.org
VideoGIE
followed by antegrade placement of the metal stent (Zilver 635, Cook Medical, Bloomington, IN, USA) above the ampulla of Vater (Fig. 1B) and dilation with a 4-mm balloon. Finally, we performed EUS-guided hepaticojejunostomy (Niti-S biliary covered stent). The patient recovered without any adverse events. The stent functioned well for the remainder of the patient’s life (10 months). EUS-guided hepaticojejunostomy combined with EUS-guided antegrade stent placement offers several advantages. If occlusion of the antegrade stent occurs, the hepaticojejunostomy offers an outlet and avoids obstructive jaundice. If occlusion of both stents occurs, reintervention can be performed easily through the hepaticojejunostomy stent. Because of the 6F delivery system of the metallic stent, dilation of the fistula is not needed; therefore, the risk of bile leakage may be reduced, compared with results of a standard delivery system. The risk of misplacing the metal stent because of stent shorting is greatly reduced
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.
because of use of a laser-cut stent. This method appears to safely and effectively prevent adverse events. DISCLOSURE All authors disclosed no financial relationships relevant to this article.
ACKNOWLEDGMENT We wish to offer our special thanks to Akiko Kai. Takeshi Ogura, MD, PhD, Shoko Edogawa, MD, PhD, Akira Imoto, MD, PhD, Daisuke Masuda, MD, PhD, Second Department of Internal Medicine, Kazuhiro Yamamoto, MD, PhD, Department of Radiology, Toshihisa Takeuchi, MD, PhD, Takuya Inoue, MD, PhD, Second Department of Internal Medicine, Kazuhisa Uchiyama, MD, PhD, Department of General and Gastroenterological Surgery, Kazuhide Higuchi, MD, PhD, Second Department of Internal Medicine, Osaka Medical College, Osaka, Japan
http://dx.doi.org/10.1016/j.gie.2014.05.323
Three late adverse events of choledochoduodenostomy of which the endoscopist should be aware: direct retrograde cholangioscopy is helpful for diagnosis and therapy
Figure 1. Direct retrograde cholangioscopy (DRC) in a 45-year-old female patient with Todani Type 5 biliary cysts (Caroli’s disease) and adenocarcinoma at the site of the CD.
Choledochoduodenostomy (CD) is a rarely performed surgical procedure in patients with distal biliary obstruc-
tion or adenoma of the ampulla of Vater. In this video presentation, we comment on 3 scenarios of late adverse
www.giejournal.org
Volume 81, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 463
dilated papillary orifice, and direct cholangioscopy was performed. An electrohydraulic lithotripsy probe progressively fractured the stone until the surgical clip nidus was visualized. The clip was freed and removed by using forceps. After stone retrieval, a 7F, 7-cm plastic biliary stent was placed, and the patient was treated with antibiotics for 5 days. This case describes the successful use of singleballoon enteroscopy to perform direct peroral cholangioscopy in a patient with surgically altered anatomy to
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.
remove a cat’s eye calculus (Video 1, available online at www.giejournal.org). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. None of the editors acted as a reviewer for this article. Ryan Law, DO, Division ogy, Mayo Clinic, H. Baron, MD, FASGE, Hepatology, University of Carolina, USA
of Gastroenterology and HepatolRochester, Minnesota, Todd Division of Gastroenterology and North Carolina, Chapel Hill, North
http://dx.doi.org/10.1016/j.gie.2014.04.031
EUS-guided hepaticojejunostomy combined with antegrade stent placement
Figure 1. A, Successful insertion of the guidewire into the intestine. B, We performed EUS-guided antegrade stent placement by using a Zilver 635 stent (6 cm 10 mm, uncovered, with 6F delivery system).
We describe herein technical tips of EUS-guided hepaticojejunostomy combined with EUS-guided antegrade stent placement by using a fine-gauge delivery system. A 39-year-old woman who had undergone total gastrectomy with a Roux-en-Y procedure developed obstructive jaundice during postoperative chemotherapy. Her carcinoembryonic antigen level was elevated (82 mg/dL; normal, !5 mg/dL). A CT scan showed extrinsic obstruction of 462 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 2 : 2015
the proximal-to-middle common bile duct. We decided to perform EUS-guided hepaticojejunostomy. We punctured the intrahepatic bile duct by using a 19gauge needle from the jejunum, then inserted a 7F tapered ERCP catheter and advanced a guidewire into the intestine across the site of bile duct stenosis (Fig. 1A; Video 1, available online at www.giejournal.org). We inserted a fine-gauge delivery system without dilation of the fistula, www.giejournal.org
VideoGIE
followed by antegrade placement of the metal stent (Zilver 635, Cook Medical, Bloomington, IN, USA) above the ampulla of Vater (Fig. 1B) and dilation with a 4-mm balloon. Finally, we performed EUS-guided hepaticojejunostomy (Niti-S biliary covered stent). The patient recovered without any adverse events. The stent functioned well for the remainder of the patient’s life (10 months). EUS-guided hepaticojejunostomy combined with EUS-guided antegrade stent placement offers several advantages. If occlusion of the antegrade stent occurs, the hepaticojejunostomy offers an outlet and avoids obstructive jaundice. If occlusion of both stents occurs, reintervention can be performed easily through the hepaticojejunostomy stent. Because of the 6F delivery system of the metallic stent, dilation of the fistula is not needed; therefore, the risk of bile leakage may be reduced, compared with results of a standard delivery system. The risk of misplacing the metal stent because of stent shorting is greatly reduced
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.
because of use of a laser-cut stent. This method appears to safely and effectively prevent adverse events. DISCLOSURE All authors disclosed no financial relationships relevant to this article.
ACKNOWLEDGMENT We wish to offer our special thanks to Akiko Kai. Takeshi Ogura, MD, PhD, Shoko Edogawa, MD, PhD, Akira Imoto, MD, PhD, Daisuke Masuda, MD, PhD, Second Department of Internal Medicine, Kazuhiro Yamamoto, MD, PhD, Department of Radiology, Toshihisa Takeuchi, MD, PhD, Takuya Inoue, MD, PhD, Second Department of Internal Medicine, Kazuhisa Uchiyama, MD, PhD, Department of General and Gastroenterological Surgery, Kazuhide Higuchi, MD, PhD, Second Department of Internal Medicine, Osaka Medical College, Osaka, Japan
http://dx.doi.org/10.1016/j.gie.2014.05.323
Three late adverse events of choledochoduodenostomy of which the endoscopist should be aware: direct retrograde cholangioscopy is helpful for diagnosis and therapy
Figure 1. Direct retrograde cholangioscopy (DRC) in a 45-year-old female patient with Todani Type 5 biliary cysts (Caroli’s disease) and adenocarcinoma at the site of the CD.
Choledochoduodenostomy (CD) is a rarely performed surgical procedure in patients with distal biliary obstruc-
tion or adenoma of the ampulla of Vater. In this video presentation, we comment on 3 scenarios of late adverse
www.giejournal.org
Volume 81, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 463
