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Armellini et al. Mini-invasive Surg 2018;2:23 I http://dx.doi.org/10.20517/2574-1225.2018.07 Page 3 of 6

A B

Figure 1. (A) Rendez-vous attempt from the duodenal bulb. The wire was positioned through the papilla, but it could not be retrieved
because of the duodenal stenosis. After a few attempts the wire had to be retracted as it can be seen in the stomach (B)

ary tree. A 0.025-inch guidewire was passed through the 19G needle that was positioned in the common
bile duct, and the 19-gauge needle was then exchanged with a 6Fr cystotome (Endoflex, Voerde, Ger-
many), which was activated to create a communication between both visceral lumens. A 4-mm biliary
dilation balloon (MaxForce™ Biliary Balloon Dilatation Catheter, Boston Scientific, Marlborough, USA)
was used to dilate the tract and subsequently a preloaded (delivery catheter: 8.5 Fr/2.83 mm) fully covered
60 mm × 10 mm self-expandable metal stent (Biliary RX Fully Covered Stent System RMV, Boston Sci-
entific, Marlborough, USA) was easily inserted leading to satisfactory drainage. As a further measure to
avoid bile leakage and set the metal stent in a stable position, a double pig-tail plastic stent 50 mm × 7 Fr
(Advanix™ Biliary Stents, Boston Scientific, Marlborough, USA) was inserted along the conduit between
the biliary and gastrointestinal tract [Video 1]. The patient had an uneventful recovery and the jaundice
improved rapidly. He received chemotherapy for a high-grade B-cell lymphoma diagnosed on duodenal
biopsies. A CT-scan performed one month later confirmed the correct position of both stents [Figure 2].

DISCUSSION
In patients with jaundice due to malignant obstruction, EUS-BD has been studied in recent years as an
[3]
alternative to PTBD after failed ERCP. In 2001, Giovannini et al. were the first to report the creation of
a bilioduodenal anastomosis under ultrasonographic guidance in a patient with pancreatic head cancer.
Since then, experience has expanded, and various EUS-guided procedures for biliary tract diseases have
been reported, including EUS-guided rendezvous choledochoduodenostomy, hepaticogastrostomy, and
antegrade stent insertion [5-10] . Nowadays, ERCP and EUS-BD have similar success and complication rates in
experienced hands, with a lower post-procedural pancreatitis rate after EUS-BD. Furthermore, recent stud-
ies have shown that EUS-BD is associated with better clinical success rates, lower adverse events rates, and
[7]
fewer reinterventions than PTBD . A study by Dhir et al. showed an average incidence of bile leaks of
[11]
3.9% in 432 patients; where most of the leaks were mild. Serious complications, such as stent migrations in
the peritoneal cavity, sepsis, and perforations have rarely been described. Data on long-term stent patency
[7]
are scant, but do not seem to differ significantly to that of ERCP stenting .
With regards to the access route, transgastric and transduodenal endoscopic approaches have similar suc-
cess rates and complications, of more than 90% and around 20% respectively [12-16] . As a matter of fact, the
access route is often determined more by the endoscopist’s expertise or preference than by evidence-based
indications. The transhepatic route through the stomach offers the advantage of a reduced bile leakage
risk although the scope position is less stable, whereas the transduodenal route appears easier to man-
[17]
age because of direct access to the main biliary duct. In 2016, Tyberg et al. proposed an interesting ap-
proach to biliary drainage based on the anatomical condition of the patient as defined on cross-sectional