LAUSR

A 74-year-old woman was hospitalized in August 2017 for altered performance status and obstructive cholangitis due to the recurrence of an adenocarcinoma involving the head of the pancreas that had been resected 2 year previously. Disease recurrence was locoregional and causing complete stenosis of the afferent loop, which prevented access to the biliary–digestive anastomosis using an endoscope. This stenosis was responsible for the accumulation of bilirubin in the afferent loop and distension of the biliary ducts (▶Fig. 1 a, b). Antibiotics were started and a percutaneous drain was placed with technical success; however, the patient’s bilirubin level remained high (200μmol/L) despite a second attempt at drainage on day 3. After multidisciplinary discussion, it was decided to perform endoscopic drainage, given the age and the performance status of the patient, which made her not fit for a surgical approach (performance status 4). A linear echoendoscope (EG 3670 URK; Pentax, France) was placed in the stomach. The distended afferent loop, located near the gastric wall, was easily identified and endoscopic ultrasound (EUS)-guided placement of an AXIOS stent (15-mm diameter; Boston Scientific) allowed a connection to be created between the stomach and the afferent loop, thereby achieving biliary drainage (▶Fig. 1 c– i). There were no early or late complications related to this procedure. The patient’s bilirubin level decreased progressively, returning to the normal range within 3 months and was stable during the next 3 months before beginning to increase again (▶Fig. 2, ▶Video1). During this time, the patient felt better and her performance status improved (performance status 2) such that, 5 months after endoscopic drainage, she was able to resume feeding and walking, which improved her moral. At month 7, icterus recurred due to hepatic hilum obstruction; however, this time, the afferent loop was directly accessible by passing the endoscope through the AXIOS stent. Extrinsic stenosis of hepatic hilum was confirmed by cholangiography. Metal and plastic stents were placed between the intraheE-Videos