Endoscopic ultrasound-directed transduodenal endoscopic retrograde cholangiopancreatography in a patient with a duodenal switch for complex stone management.

BACKGROUND AND AIMS: A 69-year-old male patient with a previous duodenal switch surgery presented with choledocholithiasis and cholangitis. Initially, interventional radiology (IR) performed biliary stent placement with a metal stent left in situ. One year later, the patient presented again with cholangitis, now requiring definitive treatment via EUS-directed transduodenal ERCP (EDDE).

METHODS

An anastomosis was created between the first portion (superior portion) of the duodenum (D1) and the excluded second portion (descending portion) of the duodenum (D2) using a lumen-apposing metal stent (LAMS). After anastomosis maturation, the patient returned for ERCP and removal of the IR-placed stent. The previously placed stent initially could not be removed, so a metal stent was placed within the IR-placed stent for later removal via stent-in-stent technique. Three months later, the stents were removed, and the bile duct was swept with a balloon. Stones and debris were extracted from the duct. The duodenoduodenal LAMS was removed, leaving a patent fistula in place.

RESULTS

An EDDE was successfully performed between the D1 and D2 portions of the duodenal switch. The patient was asymptomatic and stent-free.

CONCLUSIONS

The successful completion of this procedure indicates that it may be safe and effective to perform an EDDE in patients with duodenal switch anatomy.