Transenteric anastomosis with lumen-apposing metal stent as a conduit for iterative endotherapy of malignant biliary obstruction in altered anatomy

摘要

EUS-guided transenteric anastomosis was performed in a patient with Roux-en-Y anatomy with recurrent malignancy to allow endoscopic access for biliary drainage. Procedural steps were tested in a porcine model of EUS-guided gastrojejunostomy by using lumen-apposing metal stents (LAMSs).A 65-year-old man developed jaundice caused by a recurrent Klatskin tumor 12 months after he underwent a left hepatectomy with a 3-segment right hepaticojejunos-tomy. Incomplete transhepatic biliary drainage (percutaneous and EUS-guided) prompted enteroscopy-based ERCP, but stent insertion failed. A nasobiliary drain was left in the afferent loop, and saline solution was instilled to facilitate puncture under EUS guidance from the duodenal bulb, followed by 10 x 15-mm LAMS placement across the puncture tract. After maturation of this duode-nojejunostomy, a gastroscope was advanced through the LAMS, and double plastic biliary stents were placed (Fig. 1A; Video 1, available online at www.giejournal.org). A covered duodenal self-expandable metal stent (SEMS) was used to prevent a bypass effect through the LAMS. Jaundice reoccurred because of malignant jejunal involvement. The duodenal SEMS was removed, and another enteral SEMS was placed antegrade into the afferent loop (Fig. IB). Two further plastic biliary stents were placed across the enteral SEMS mesh. The patient died 90 days later without further adverse events.Transenteric EUS-guided LAMS anastomosis can be considered as a conduit for palliative biliary decompression in patients with altered anatomy when less-invasive approaches fail.