Single-session endoscopic ultrasound-guided tissue acquisition followed by choledochoduodenostomy in a patient with Roux-en-Y reconstruction
Year: 2024
Type: article
Study design: Case Report
Abstract: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) through the afferent limb of a Roux-en-Y reconstruction is possible but challenging [ 1 ] [ 2 ]. In reconstructed patients with subsequent distal malignant biliary obstruction, EUS-TA with endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) potentially achieves both pathological diagnosis and biliary drainage in a single session. A 78-year-old man, with a history of total gastrectomy 8 years previously for poorly differentiated gastric adenocarcinoma, was admitted with distal malignant biliary obstruction and acute cholangitis possibly due to post-gastrectomy lymph node recurrence or stage III pancreatic cancer ([ Fig. 1 ]). Single-session EUS-TA followed by EUS-CDS was performed for pathological diagnosis and biliary drainage ([ Video 1 ]). First, we inserted a balloon-assisted endoscope (EI-580BT; Fujifilm, Tokyo, Japan) into the end of the afferent limb. Second, we placed a 0.035-inch ultra-stiff guidewire (Wrangler SUS, Piolax, Yokohama, Japan) through the surgically altered intestine for echoendoscope navigation. Third, an oblique-viewing echoendoscope (EG-580UT, Fujifilm) was advanced to around the pancreatic head using the over-the-guidewire technique [ 2 ]. Fourth, EUS-TA was performed on the mass using a 22-gauge Franseen needle ([ Fig. 2 ] a ). Finally, we attempted EUS-CDS as follows: biliary puncture using a 19-gauge lancet needle, 0.025-inch guidewire placement, electrocautery anastomosis dilation, and deployment of a covered self-expandable metallic stent, 10mm in diameter and 8cm in length ([ Fig. 2 ] b ). The whole clinical course was uneventful. The patient recovered from acute cholangitis and received appropriate chemotherapy following a definitive diagnosis of well-differentiated pancreatic adenocarcinoma, ruling out lymph node recurrence from the previous gastric cancer ([ Fig. 3 ]). Fig. 1 Contrast-enhanced computed tomography (CT) image in coronal section. CT reveals a hypodense mass with a hyperdense rim around the pancreatic head. Quality: mobile 360 480 720 Download Single-session endoscopic ultrasound-guided tissue acquisition followed by choledochoduodenostomy in a patient with Roux-en-Y reconstruction.Video 1 Fig. 2 Endoscopic ultrasound-guided tissue acquisition followed by choledochoduodenostomy via the afferent limb. a Endoscopic ultrasound-guided tissue acquisition is performed using a 22-gauge Franseen needle. b Following endoscopic ultrasound-guided choledochoduodenostomy, a covered self-expandable metallic stent is deployed. Fig. 3 Specimen obtained by endoscopic ultrasound-guided tissue acquisition. The specimen shows well-differentiated adenocarcinoma with pancreatic stroma and no involvement of lymph node structures, distinguishing it from lymph node metastasis of poorly differentiated gastric adenocarcinoma. In patients with Roux-en-Y reconstruction and distal malignant biliary obstruction, tissue acquisition, and biliary drainage via the endoscopic ultrasound-guided hepaticogastric route is an alternative [ 3 ] [ 4 ]. However, intraductal biliary tissue acquisition has an inferior diagnostic yield compared with that of EUS-TA [ 5 ]. In this case, EUS-TA combined with EUS-CDS through the afferent limb facilitated simultaneous pathological diagnosis and drainage. Endoscopy_UCTN_Code_TTT_1AS_2AF Endoscopy E-Videos https://eref.thieme.de/e-videos E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos . Publication History Article published online: 12 August 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany
Source: Endoscopy
DOI: 10.1055/a-2368-4205
Institution: Gamagori City Hospital
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4401505835