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EUS-guided choledochoduodenostomy using an antimigration metal stent with a thin delivery system for tract dilatation (with video)

 Second Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

Date of Submission16-Mar-2021
Date of Acceptance07-Jul-2021
Date of Web Publication14-Nov-2021

Correspondence Address:
Masayuki Kitano,
Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-0012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00073

PMID: 34782491

How to cite this URL:
Itonaga M, Hatamaru K, Kitano M. EUS-guided choledochoduodenostomy using an antimigration metal stent with a thin delivery system for tract dilatation (with video). Endosc Ultrasound [Epub ahead of print] [cited 2022 Sep 24]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=329901

EUS-guided choledochoduodenostomy (EUS-CDS) is the procedure of choice when ERCP fails in patients with distal bile duct obstruction.[1],[2] However, adverse events such as bile leakage and stent migration after EUS-CDS occur in 17.9%–23.3% of cases.[3] To reduce adverse events, we previously developed a metal stent with a thin delivery system (7.5Fr). EUS-CDS with this stent was associated with a technical success rate of 95%, a clinical success rate of 100%, and an adverse event rate of 5%.[4] The delivery system could be successfully inserted into the bile duct without the use of a fistula dilation device in 31.6% (6/19) of the procedures. Recently, the diameter of the delivery system for this metal stent was further reduced in diameter (7.0Fr) to reduce the need for fistulous-tract dilation [Figure 1].[5] This stent has two advantages over conventional stents. First, the delivery system, consisting of a thin shaft and a tapered tip, facilitates insertion into the bile duct without the use of a fistulous tract dilation device and prevents bile leakage during the procedure. Second, the stent is made of a laser-cut wire and has a flared structure at both ends. These features can prevent stent migration. Here, we outline the procedures for EUS-CDS without fistula dilation using the novel thin delivery system stent [Figure 2] and [Video 1 [Additional file 1]] and [Video 2 [Additional file 2]]. First, a 19-gauge fine aspiration needle (SonoTip Pro Control 19G, Medi-globe, Germany) was used to puncture the extrahepatic bile duct under endosonographic guidance. After aspiration of the bile juice, a contrast medium was injected and a 0.025-inch angle-tip guidewire (VisiGlide 2; Olympus Medical Systems, Tokyo, Japan) was inserted into the common bile duct such that its tip was advanced toward the upstream bile duct. Thereafter, we inserted the thin delivery system stent via the fistula without using any dilation device. The release was started under echo guidance, and the distal end was fully expanded and its position adjusted. Then, stent expansion was continued into the channel while maintaining close contact between the tip of the echoendoscope and the duodenal wall. Finally, after checking the proximal side of the stent on the endoscopic image, stent expansion was completed.
Figure 1: The stent and delivery system (Covered BileRush Advance, Piolax Medical Devices, Yokohama, Japan). (a) The expanded stent is 8 mm in diameter and 60 mm in length. The stent is made of laser-cut wire and has a flared structure at both ends. These features can prevent stent migration. (b) This stent is delivered with a 7.0 Fr. pull-back delivery catheter. The tip of the delivery system is shaped (2.6Fr) to enable stent deployment without fistula dilation

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Figure 2: EUS-guided choledochoduodenostomy using a novel thin delivery system stent. (a) EUS image showing a 19-gauge needle advanced into the extrahepatic bile duct. (b) EUS image showing stent release under EUS guidance. (c) Fluoroscopic image showing stent placement. (d) Endoscopic image showing the fully opened proximal flange

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Conflicts of interest

There are no conflicts of interest.

  References Top

Isayama H, Nakai Y, Itoi T, et al. Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018. J Hepatobiliary Pancreat Sci 2019;26:249-69.  Back to cited text no. 1
Minaga K, Kitano M. Recent advances in endoscopic ultrasound-guided biliary drainage. Dig Endosc 2018;30:38-47.  Back to cited text no. 2
Wang K, Zhu J, Xing L, et al. Assessment of efficacy and safety of EUS-guided biliary drainage: A systematic review. Gastrointest Endosc 2016;83:1218-27.  Back to cited text no. 3
Itonaga M, Kitano M, Hatamaru K, et al. Endoscopic ultrasound-guided choledochoduodenostomy using a thin stent delivery system in patients with unresectable malignant distal biliary obstruction: A prospective multicenter study. Dig Endosc 2019;31:291-8.  Back to cited text no. 4
Minaga K, Kitano M, Itonaga M, et al. Endoscopic ultrasound-guided biliary drainage using a newly designed metal stent with a thin delivery system: A preclinical study in phantom and porcine models. J Med Ultrason (2001) 2018;45:391-7.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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