Endoscopic ultrasound-guided choledocal duodenostomy using a lumen-opposing metal stent in a patient with pre-existing duodenal stent and ascites. A 67-year-old female with metastatic breast adenocarcinoma with peritoneal carcinomatosis, history of gastric outlet obstruction, status post-duodenal stents presented with painless obstructive jaundice. The total bilirubin at the time of presentation was 8.3. MRI abdomen was performed and showed new moderate to severe dilatation of the intra-hepatic ducts and the common bowel duct. Extensive retroperitoneal metastatic disease was seen, obstructing the common bowel duct and the pancreatic duct entering into the duodenum. Severe diffuse peritoneal and mesenteric soft tissue thickening was also noted with trace ascites. ERCP was first attempted, which showed an edematous major papilla found within the metal mesh. The ampullary access was extremely limited due to the distorted anatomy. Therefore, the biliary cannulation was not possible. This was followed by endoscopic ultrasound, which showed moderate to severe dilatation of the intra-hepatic ducts and common bowel duct. The common bowel duct measured 13.7 millimeter. A mild to moderate amount of ascites was noted in the peritoneal cavity that precluded the possibility of performing US-guided hepatic gastrostomy. Because of the acute angulation and interference of the proximal end of the duodenal stent in the duodenal bulb, an access through the intrapancreatic portion of the bowel duct was thought to be impossible. After prolonged examination from multiple locations, a clear window was seen just proximal to the stent within the duodenal bulb. At this point, one-step placement of a small lumen-opposing metal stent was thought to be ideal, reducing the risk of bowel leak and allowing adequate biliary drainage. In this case, we planned direct US-guided choledochondutenostomy. A long-angled 0.025 guide wire and a 6 by 8 millimeter cautery-enhanced lamps was used for this procedure. The distance between the duodenum and the bowel duct was 8.3 millimeter, and there was mild ascites noted between the duodenum and the bowel duct. The bowel duct was punctured using a cautery-enhanced lamps device through the duodenal wall just proximal to the duodenal stent under US guidance in order to reduce the occurrence of bowel leak and possible infection of the ascites. The current was applied to the cautery tip, and then the tip was advanced into the dilated bowel duct, and an angled 0.025 inch guide wire was advanced towards the proximal bowel duct. A small lamps device was advanced into the bowel duct over the wire, and the stent was placed with the flanges in close approximation to the walls of the bowel duct and the duodenum. Excellent bowel drainage was confirmed with an upper endoscope. The position of the lumen-opposing metal stent was noted just proximal to the duodenal stent within the duodenal bulb. There was no adverse events noted after the procedure. She had no post-procedural abdominal pain. On next day, she was tolerating sock tide. Her total bilirubin was down to 2.6, and she was discharged home on a seven-day course of antibiotics. At three months follow-up, the patient was clinically doing well with normalization of the total bilirubin. US-guided Colodoco duodenostomy was relatively smooth with a new smaller format of lamps, given the flexibility of the device to deploy the stent. The benefits of the smaller format is that it allows the insertion of the stent in a small window of stent placement and the short distance that it needs to be advanced into the duct. This is a great advantage for US-guided Colodoco duodenostomy because it fits the angle it usually needs to concur, that is, angle of needle insertion to the duct towards the hilum. In this case, mild to moderate amount of ascites was seen during US evaluation. This was a concern, but direct-access single-step stent placement was effective with no post-procedural pain. US-guided Colodoco duodenostomy with a smaller configuration lumen-opposing metal stent is a promising option for effective biliary decompression in malignant biliary obstruction with a pre-existing duodenal stent when other endoscopic interventions are not technically feasible. Smaller caliber of the stent helps target the small window proximal to the duodenal stent, avoiding stent-in-stent insertion. This may also contribute to the reduction of some syndrome. One-step placement of the fully covered lumen-opposing metal stent likely would minimize the chance of bile leak, making this device ideal for the procedure.

metastatic breast cancer

obstructive jaundice

endoscopic ultrasound-guided choledocal duodenostomy

lumen-opposing metal stent

biliary decompression