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Altered anatomy: An EUS-guided placement of a lumen-apposing metal stent for successful ERCP following Whipple procedure (with video)

1 Montefiore Medical Center, Albert Einstein College of Medicine; Department of Internal Medicine, Montefiore Medical Center, Bronx, NY, USA
2 Montefiore Medical Center, Albert Einstein College of Medicine; Department of Gastroenterology, Montefiore Medical Center, Bronx, NY, USA

Date of Submission24-Feb-2021
Date of Acceptance30-Nov-2021
Date of Web Publication02-May-2022

Correspondence Address:
Kazi I Ullah,
1958 Gleason Avenue, Bronx, NY 10472
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00058

How to cite this URL:
Ullah KI, Bhardwaj M, Ho S. Altered anatomy: An EUS-guided placement of a lumen-apposing metal stent for successful ERCP following Whipple procedure (with video). Endosc Ultrasound [Epub ahead of print] [cited 2022 May 22]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=344242

Increased prevalence of surgically altered anatomy in patients with biliary obstruction presents a technical challenge to endoscopists. Novel approaches employing EUS in altered postsurgical anatomy have been described but are limited.[1] This is a case of a EUS-guided lumen-apposing metal stent (LAMS) placement for successful ERCP in a patient with recurrent cholangitis following pancreaticoduodenectomy.

The patient is a 75-year-old woman with a history of intraductal papillary mucinous neoplasms treated with Whipple pancreaticoduodenectomy complicated by strictures and recurrent cholangitis. Prior ERCPs were unsuccessful since the standard duodenoscope was too short to access the biliary anastomosis in the altered anatomy. We placed a EUS-guided gastrojejunal LAMS to create a direct passageway from the stomach into the afferent limb for future ERCPs [Video 1 [Additional file 1]]. First, we advanced a balloon into the afferent limb in the direction of the jejunal-gastro-anastomosis. The balloon was inflated, and the remaining blind jejunal end was distended with a solution of contrast, normal saline, and methylene blue [Figure 1]. With EUS guidance, an LAMS was introduced from the stomach into the distended loop of small bowel successfully, creating a direct connection between the stomach and the afferent limb of her pancreaticoduodenectomy [Figure 2] and [Figure 3]. In subsequent admissions, the standard duodenoscope was advanced through the previously placed LAMS into the afferent limb where the bile duct was cannulated and decompressed for relief of the patient's recurrent cholangitis [Figure 4].
Figure 1: Endoscopic Ultrasound View of contrast-filled biliary limb

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Figure 2: Distended Biliary Limb - Fluoroscopic View

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Figure 3: Deployment of Lumen Apposing Metal Stent - Endoscopic Ultrasound View

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Figure 4: Lumen Apposing Metal Stent in position - Fluoroscopic View

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EUS-guided LAMS placement allows for a minimally invasive approach to circumvent surgically altered anatomy in an attempt to relieve biliary obstruction using standard duodenoscopes. While the current evidence is limited, it supports the efficacy and safety of this method. In expert centers, EUS-guided access to the pancreaticobiliary system has yielded high technical and clinical success rates at 94.7% and 91.7%, respectively.[2] Postprocedure complications were limited to perforation and bleeding in 2.2% and 1.1% of patients, respectively.[3] We hope that our case adds to the body of literature that supports the use of a EUS-guided placement of LAMS to enable endoscopic access for successful ERCP in surgically altered anatomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

Sammy Ho is an Editorial Board Member of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of this editor and his research groups.

  References Top

Krutsri C, Kida M, Yamauchi H, et al. Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. World J Gastroenterol 2019;25:3313-33.  Back to cited text no. 1
Shah RM, Tarnasky P, Kedia P. A review of endoscopic ultrasound guided endoscopic retrograde cholangiopancreatography techniques in patients with surgically altered anatomy. Transl Gastroenterol Hepatol 2018;3:90.  Back to cited text no. 2
Jain D, Shah M, Patel U, et al. Endoscopic ultrasound guided choledocho-enterostomy by using lumen apposing metal stent in patients with failed endoscopic retrograde cholangiopancreatography: A literature review. Digestion 2018;98:1-10.  Back to cited text no. 3


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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