Candy-like sign during endoscopic ultrasound-guided choledochoduodenostomy as an indication of the long distance between the bile duct and duodenal wall

Endoscopic ultrasound-guided choledocoduodenostomy (EUS-CDS) using a covered self-expandable metallic stent (SEMS) is an established alternative drainage technique for patients in whom endoscopic retrograde cholangiopancreatography has failed [1] [2]. This report describes the case of a patient who underwent successful EUS-CDS with a partially covered SEMS placed far from the duodenal wall.

A 66-year-old man with locally advanced pancreatic head cancer was admitted to our hospital. He had undergone percutaneous transhepatic biliary drainage (PTBD) at another hospital 1 week earlier because of failed selective bile duct cannulation. He experienced right flank pain after PTBD. As the patient wanted the PTBD tube removed, we opted to perform EUS-CDS rather than antegrade stenting.

After puncture of the common bile duct from the first part of the duodenum using a 19-gauge needle (Echo Tip Ultra; Cook Japan, Tokyo, Japan), a 0.025-inch guidewire (VisiGlide; Olympus Medical Systems Corp., Tokyo, Japan) was inserted into the intrahepatic bile duct. Fistula dilation was then performed using a 6-Fr wire-guided diathermic dilator (Cysto-Gastro-Set; Endo-Flex Gmbh, Voerde, Germany) with a blended cut mode. Insertion of a partially covered SEMS (WallFlex, 10 × 60 mm; Boston Scientific Japan, Tokyo, Japan) was then attempted through the fistula. The EUS-CDS procedure was performed quickly; however, the SEMS revealed a candy-like sign in the form of a large gap between the bile duct and duodenum, and this sign warrants caution as it indicates distal migration and bile leakage ([Fig. 1] and [Fig. 2]; [Video 1]).

Fig. 1 Radiographic image showing the candy-like sign of a partially covered self-expandable metallic stent resulting from a large gap between the common bile duct and the duodenal wall during endoscopic ultrasound-guided choledochoduodenostomy.

Fig. 2 Endoscopic image showing migration of the distal end of the partially covered self-expandable metallic stent during endoscopic ultrasound-guided choledochoduodenostomy.

Endoscopic rescue technique for gap formation of the partially covered self-expandable metallic stent (SEMS), which was dilated using a balloon catheter followed by placement of a fully covered SEMS.

We therefore attempted additional stenting using a fully covered SEMS (Bonastent, 10 × 60 mm; Standard Sci Tech, Seoul, Korea), but this stent could not be passed through the first partially covered stent. Balloon dilation (Hurricane RX Biliary Balloon Dilation Catheter; Boston Scientific Japan) of the first partially covered SEMS was performed ([Fig. 3]; [Video 1]). Finally, a second fully covered SEMS was placed across the fistula through the first partially covered stent without any complication ([Fig. 4] and [Fig. 5]; [Video 1]).

Fig. 3 Radiograph showing balloon dilation of the first partially covered self-expandable metallic stent.

Fig. 4 Radiograph showing the second fully covered self-expandable metallic stent (SEMS) placed across the first partially covered SEMS.

Fig. 5 Endoscopic image showing the second fully covered self-expandable metallic stent (SEMS) advanced over a guidewire through the first partially covered SEMS.

We were successful in saving this patient using placement of an additional fully covered SEMS. Caution should be taken in the event of the rare and dangerous candy-like sign, which indicates a long distance between the bile duct and duodenum, during EUS-CDS with covered SEMS placement.

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• References

• 1 Itoi T, Isayama H, Sofuni A et al. Stent selection and tips on placement technique of EUS-guided biliary drainage: transduodenal and transgastric stenting. J Hepatobiliary Pancreat Sci 2011; 18: 664-672
• 2 Kawakubo K, Isayama H, Kato H et al. A multicenter retrospective study of endoscopic ultrasound-guided biliary drainage (EUS-BD) for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 2014; 21: 328-334