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Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) is a potential procedure for primary drainage in unresectable malignant distal biliary obstruction and can replace endoscopic retrograde cholangiopancreatography. However, adverse events following EUS-CDS are occasionally reported, the most common being bile leak due to fistula dilation [1, 2]. The safety of EUS-CDS without fistula dilation using two types of thin, fully covered self-expandable metallic stents (FCSEMSs) has been previously reported [3–5]. Here we report a case in which EUS-CDS without fistula dilation was successfully performed using a novel FCSEMS with a 5.9-Fr delivery system (Hanarostent Benefit; M.I.Tech, Seoul, Korea) (▶Fig. 1). A 62-year-old man who had received chemotherapy for unresectable pancreatic body cancer developed a distal biliary obstruction. Computed tomography revealed a 25-mm mass on the pancreatic body and a dilated common hepatic duct (CHD) (▶Fig. 2 a). We performed EUS-CDS for primary drainage. The dilated CHD was localized using a forward-viewing echoendoscope (TGFUC260J; Olympus Medical Systems, Tokyo, Japan) from the duodenal bulb (▶Fig. 2b). First, the CHD was punctured with a 19-gauge needle (EZ Shot 3 Plus; Olympus Medical Systems). Cholangiography revealed a dilated CHD with distal obstruction. Second, a 0.025-inch guidewire (M-Through; ASAHI INTECC Corp., Tokyo, Japan) was inserted into the B4 branch. Fistula dilation was avoided, and the novel FCSEMS (8mm×6cm) was passed through the duodenum and CHD wall smoothly. Finally, the stent was placed in the CHD from the duodenal bulb (▶Fig. 3, ▶Fig. 4; ▶Video 1). No adverse events occurred during or after the procedure. In previous reports, EUS-CDS without fistula dilation was performed using the FCSEMSs with a 7-Fr or 7.5-Fr delivery system, with 31.6%–100% technical success rate [3–5]. This is the first report discussing EUS-CDS without fistula dilation using a FCSEMS with a 5.9-Fr delivery system, which is the thinnest ever commercially available delivery system and is capable of simpler and safer EUS-CDS procedures.

endoscopy

Endoscopic ultrasound-guided choledochoduodenostomy without fistula dilation using a novel fully covered metallic stent with a 5.9-Fr ultra-thin delivery system