ASGE DDW Videos from Around the World | 2023-EUS-DIRECTED TRANS-ENTERIC ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY WITH GIANT INTRAHEPATIC STONE LITHOTRIPSY AFTER LAMS-IN-LAMS RESCUE OF A MISDEPLOYMENT

Video Transcription

Endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography after a lumps-in-lumps rescue of a misdeployment.  Endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography  is one emerging alternative for bilary interventions in patients with Roux-en-Y hepatico-jejunostomy.  An 80-year-old woman with a former surgical Roux-en-Y hepatico-jejunostomy for complex choledocholithiasis was admitted for cholangitis.  Amnetic resonance showed a 40 mm stone above the bilodigestive anastomosis. After discussion of alternatives, endoscopic ultrasound-directed transenteric ERCP was proposed.  Firstly, we performed over-the-wire release of electrocauterin-enhanced lumen-opposing metal stand. Lumps misdeployment was addressed with lumps-in-lumps rescue strategy.  38 hours later, a gasoscope was easily passed through the lumps to reach the bilodigestive anastomosis.  A electrophoretic lithotripsy was used to fragment the stone with complete bilary clearance. In this MRI picture, we can see the giant stone above the bilodigestive anastomosis.  The biliary loop was identified under his guidance through the stomach and punctured with a 19 gauge needle. The biliary loop was distended with saline mixed with contrast medium.  An over-the-wire 15 mm lump was advanced and deployed.  The LAMS was immediately dilated up to 15 mm.  After introducing a therapeutic gastroscope, misdeployment of the distal flange of the LAMS in the peritoneal cavity was visible.  Peritoneum and valery loop with a large enterotomy were clearly visible through the LAMS. The enterotomy was therefore intubated with the gastroscope.  A new 20 mm LAMS was therefore released over the wire. The distal flange was released inside the loop and then pulled up so that the valery loop overlapped the gastric wall.  The gastroscope was retracted in the stomach and the proximal flange released inside the former LAMS in the gastric lumen. The new LAMS was dilated up to 12 mm.  Contrast injection showed no leak. After 38 hours the patient underwent through the LAMS urcp through a therapeutic gastroscope.  A therapeutic gastroscope was advanced through the LAMS towards the bilodigestive anastomosis.  The giant stone was managed by electrohydraulic lithotripsy.  Stone fragments were removed through basket, balloon, saline injection and aspiration.  Complete bioreclearance was obtained.  Endoscopic ultrasound-directed transenteric ERCP represents an alternative for repeated bilary interventions in Rheum-Y hepatico-jejunostomy.  LAMS misdeployment might represent a serious complication.  A larger LAMS-in-LAMS rescue might allow to uneventfully complete the anastomosis and perform, through the LAMS, therapeutics.  Thank you.

Video Summary

The video discusses the case of an 80-year-old woman who had previously undergone a surgical procedure called Roux-en-Y hepatico-jejunostomy for complex choledocholithiasis (gallstones in the bile ducts). She was admitted for cholangitis (inflammation of the bile ducts) and had a large stone above the bilodigestive anastomosis (join between bile duct and digestive system). The video demonstrates the use of endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography (ERCP) to treat this condition. The procedure involves the deployment of various instruments, such as electrocautery, a lumen-opposing metal stent, and electrophoretic lithotripsy to break down the stone and achieve biliary clearance. This alternative procedure is considered for patients with Roux-en-Y hepatico-jejunostomy who require repeated biliary interventions. The video also highlights the potential complication of misdeployment of the lumen-apposing metal stent, which can be addressed through a "lumps-in-lumps rescue" strategy. Overall, the video provides insights into the endoscopic treatment options and challenges for patients with complex biliary conditions. No specific credits are granted for this video.

Asset Subtitle

World Cup
Authors: Giuseppe Vanella, Giuseppe Dell'Anna, Paolo G. Arcidiacono

Keywords

Roux-en-Y hepatico-jejunostomy

choledocholithiasis

cholangitis

endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography

biliary clearance