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Endoscopy
Endoscopy
10.1055/s-00000012
Endoscopy
Endoscopy
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10.1055/a-2387-4238
E-Videos-2024-06-5151-EV
E-Videos
Antegrade metallic stent placement using a slim cholangioscope for malignant afferent loop obstruction
http://orcid.org/0000-0001-6324-5433
Miwa Haruo MD, PhD
Oishi Ritsuko Dr.
Endo Kazuki Dr.
Tsuchiya Hiromi Dr.
Funaoka Akihiro Dr.
Suzuki Yuichi Dr.
Maeda Shin
1 26437 Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
2 Department of Gastroenterology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
Correspondence Haruo Miwa, MD, PhD Gastroenterological Center, Yokohama City University Medical Center4-57 Urafune-choMinami-ku, Yokohama, Kanagawa 232-0024Japanmiwa@yokohama-cu.ac.jp
04 9 2024
12 2024
1 9 2024
56 Suppl 1 E774E775
The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
2024
The Author(s).
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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pmc Enteral metallic stent placement using balloon enteroscopy is reported as a therapeutic strategy for malignant afferent loop obstruction 1 2 ; however, it is challenging when the enteroscope cannot reach the stricture. Metallic stent placement via endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is rarely reported in such difficult conditions 3 4 . Here we report antegrade metallic stenting using a slim cholangioscope for malignant afferent loop obstruction ( Video 1 ).

Antegrade metallic stent placement for malignant afferent loop obstruction was performed under guidance of a slim cholangioscope.

Video 1

A 78-year-old man who underwent pancreaticoduodenectomy with Roux-en-Y reconstruction was referred to our hospital with a benign hepaticojejunostomy anastomotic stricture. EUS-HGS was performed because balloon enteroscopy could not reach the afferent loop ( Fig. 1 ). The patient developed cholangitis 2 years later due to a malignant afferent loop obstruction with abdominal dissemination ( Fig. 2 ). Enteral metallic stent placement was performed via the EUS-HGS route ( Fig. 3 ). An endoscopic retrograde cholangiopancreatography catheter was inserted into the afferent loop; however, a guidewire could not pass through the stricture. A slim cholangioscope (9-Fr eyeMAX; Micro-Tech, Nanjing, China) was inserted into the afferent loop via the EUS-HGS and hepaticojejunostomy anastomoses. The guidewire was then successfully passed through the stricture using a cholangioscope. Contrast-enhanced imaging revealed a localized stricture in the afferent loop. After cholangioscope removal, a balloon dilation catheter was inserted; however, it could not pass through the stricture. A guide sheath (UMIDAS sheath cannula; UMIDAS Inc., Kanagawa, Japan) was inserted into the stricture and a biliary metallic stent with an ultraslim delivery system (YABUSAME Neo; KANEKA Medics, Tokyo, Japan) was successfully passed and placed through the guide sheath. Contrast agent flowed out through the metallic stent and the patient’s abdominal pain was relieved.

Fig. 1 Fluoroscopic images. a A single-balloon enteroscope could not reach into the afferent loop. b Endoscopic ultrasound-guided hepaticogastrostomy was performed for hepaticojejunostomy anastomotic stricture.

Fig. 2 Computed tomography showed a dilated afferent loop due to a malignant stricture.

Fig. 3 Fluoroscopic images. a An endoscopic retrograde cholangiopancreatography catheter was inserted into the afferent loop and the stricture was revealed. b The guidewire was passed through the stricture under guidance of the slim cholangioscope. c A metallic stent with ultraslim delivery was inserted through the guide sheath. d The stent was successfully placed, and the contrast agent flowed out.

To the best of our knowledge, this is the first report of antegrade metallic stent placement using cholangioscopy in a case of malignant afferent loop obstruction. This case demonstrates that a slim cholangioscope may aid guidewire placement in difficult conditions.

Endoscopy_UCTN_Code_TTT_1AR_2AZ

Endoscopy E-Videos https://eref.thieme.de/e-videos

E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos .

Conflict of Interest The authors declare that they have no conflict of interest.
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References

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