One-step primary endoscopic ultrasound-guided choledochoduodenostomy without lumen-apposing metal stent using a Franseen needle and an ultra-stiff high-sliding guidewire

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) using a lumen-apposing metal stent (LAMS) can be used as a primary treatment for malignant distal biliary obstruction because of its higher technical success rates and shorter procedure times than conventional transpapillary metal stent placement [1] [2]. However, it is unsuitable for minimally dilated common bile ducts (CBDs) and thin 6-mm-diameter LAMSs are commonly used owing to large flanges. Other disadvantages include high costs, early stent dysfunction, and adverse events caused by biliary wall compression, duodenobiliary reflux, and cautery puncture [3]. Conversely, EUS-CDS with conventional metal stents requires a fistula dilation step that is time-consuming, leading to biliary peritonitis and a high risk of stent migration. Therefore, we propose a novel one-step EUS-CDS method without a LAMS using a Franseen needle and an ultra-stiff, high-sliding guidewire.

The Franseen needle creates a larger-diameter fistula during puncture than standard needles [4] ([Fig. 1]). The 0.035-inch guidewire has a thick, high-rigidity nickel-titanium core and polytetrafluoroethylene coating with “ridge-processing” to minimize the contact area and friction, enhancing device followability and insertability ([Fig. 2]). This combination can eliminate the need for fistula dilation even when inserting a thick delivery system. A dumbbell-shaped metal stent [5] was employed for stenting owing to its antimigration properties.

Fig. 1 a, c In the bench test, the 19-G Franseen needle (SonoTip TopGain; Medi-Globe, Rohrdorf, Germany) creates a 1.27 mm-diameter hole. b, d In contrast, the 19-G standard needle (SonoTip Pro Control; Medi-Globe) creates a 0.70 mm-diameter hole.

Fig. 2 The novel guidewire measures 0.035 inches and features a thick, high-rigidity nickel-titanium core. The surface is coated with polytetrafluoroethylene, using “ridge-processing”, which reduces contact area and friction with devices, enhancing followability and insertability.

An 83-year-old man with obstructive jaundice due to malignant distal biliary obstruction was scheduled for primary EUS-CDS drainage. After CBD puncture from the duodenum using a 19-G Franseen needle (SonoTip TopGain; Medi-Globe, Rohrdorf, Germany), an ultra-stiff guidewire (SeekMaster Hard; Piolax Medical Devices, Kanagawa, Japan) was inserted into the intrahepatic bile duct. Subsequently, the 8-Fr delivery system of the dumbbell-shaped stent (BONASTENT M-Intraductal; Standard Sci-Tech Inc., Seoul, Korea) was smoothly inserted without fistula dilation, followed by placement of the stent from the CBD to the duodenum ([Fig. 3], [Video 1]). The procedure was completed within five minutes. No adverse events or stent dysfunction, including biliary peritonitis or migration, occurred until the patient’s death.

Fig. 3 a A 19-G Franseen needle was used to puncture the common bile duct from the duodenum. b The novel guidewire was inserted into the intrahepatic bile duct. c Subsequently, the 8-Fr delivery system of the dumbbell-shaped metal stent was smoothly inserted without the need for fistula dilation. d The metal stent (12 × 50 mm) was then placed from the common bile duct to the duodenum.

One-step primary endoscopic ultrasound-guided choledochoduodenostomy using a Franseen needle and an ultra-stiff, high-sliding guidewireVideo 1

This method offers a straightforward and effective primary drainage approach for malignant distal biliary obstruction, addressing the limitations of EUS-CDS with a LAMS.

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Publication History

Article published online:
08 August 2024

• References

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