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Page 2 of 6 Armellini et al. Mini-invasive Surg 2018;2:23 I http://dx.doi.org/10.20517/2574-1225.2018.07

significant morbidity and mortality rates compared with ERCP. Major complication rates after PTBD vary
between 0.5% and 2.5%. Major complications include bleeding, surgical site infections, cholangitis, bile
[1]
leaks, pneumothorax, and catheter dislodgement. Procedure-related mortality is < 2% in most series .
Endoscopic ultrasound offers real-time imaging of the bilio-pancreatic district with the possibility of guid-
ing complex procedures, including direct access to the main biliary duct and the left hepatic duct from
the stomach or duodenum. For these reasons, endoscopic ultrasound-guided biliary drainage (EUS-BD)
has been increasingly investigated, and it has been proposed as an alternative to PTBD if ERCP fails. Since
[2]
Wiersema et al. reported the first experience of endosonography-guided cholangiopancreatography, and
[3]
Giovannini et al. described the creation of a choledochoduodenal anastomosis, various EUS-guided pro-
cedures for accessing the biliary tree from the duodenum or stomach have been described. Once a biliary
duct has been punctured, either the left intrahepatic ducts from the proximal stomach or the main duct
from the duodenal bulb, a tract between the biliary tree and visceral lumen is created by a cystotome and a
stent is inserted to allow the creation of an anastomosis. Either plastic or, preferably, self-expandable metal
stents can be used, the last being fully or partially covered to minimize the risk of bile leakage. More re-
cently, a novel electro-cautery lumen-opposing self-expanding metal stent (Hot AXIOS™ stent and delivery
system) that is used to perform EUS-BD (choledocho-duodenal anastomosis) has been developed with the
[4]
promise to allow faster and safer procedures .

EUS-BD appears to be an effective technique for the treatment of biliary obstruction after unsuccessful
ERCP. However, it is a complex procedure, requiring endoscopic and ultrasonographic skills in addition
to an interventional radiology and surgical support in order to ensure a safe procedure in case of adverse
events. We herein report a case of successful EUS-DB in a patient with malignant obstruction of the com-
mon bile duct, with special emphasis on the technical aspects of this approach including a video of the
procedure.

CASE REPORT
A 71-year-old male patient with biliary obstruction was referred to our department for tissue sampling and
endoscopic biliary stenting with the view of further oncological therapy. An abdominal computed tomog-
raphy (CT) scan showed multiple abdominal adenopathies and pathological tissue involving the hepatic
hilum and the pancreatic head with dilation of the main biliary tract and minimal dilation of the intrahe-
patic biliary tree. After multidisciplinary tumor board evaluation and discussion of the therapeutic options
with the patient including the informed consent, he was scheduled for endoscopic drainage. Endoscopy was
carried out under deep sedation with midazolam and propofol. During endoscopic exploration, malignant
infiltration of the second portion of the duodenum was evidenced, which hindered the procedure after a
few ERCP attempts (TJF-240; Olympus Medical Systems, Tokyo, Japan). A stepwise approach was planned
during the same endoscopic session. After prophylactic antibiotic therapy was administered (ceftriaxone
2 g), a EUS-guided rendezvous was performed with access from the duodenal bulb to the main biliary
tract. A 0.025-inch guidewire (VisiGlide II; Olympus Medical Systems, Tokyo, Japan) was passed across
the papilla through a 19G needle (EchoTip® Ultra HD Ultrasound Access Needle, Cook Medical, Limerick,
Ireland), up to the duodenum. Wire capture via a snare passed through the duodenoscope was unsuccess-
ful due to the difficult duodenal access, and after a few attempts the guidewire had to be retrieved [Figure
1A and B]. As a second option, EUS-BD from the duodenal bulb was chosen. A linear echoendoscope
with a 3.7-mm working channel (GF-UCT180 Linear Ultrasound Endoscope, Olympus Medical Systems,
Tokyo, Japan), connected to an ultrasonographic processor (EU ME2, Olympus Medical Systems, Tokyo,
Japan) was used to visualize the main biliary tract from the duodenal bulb. Color Doppler ultrasound
was used to assess the local vascularization. The common bile duct was punctured with a 19-gauge needle
(EchoTip® Ultra HD Ultrasound Access Needle, Cook Medical, Limerick, Ireland). Under fluoroscopic
guidance, the bile was aspirated and iodine contrast medium was injected in order to delineate the bili-