LAUSR

A patient with metastatic pancreatic adenocarcinoma underwent combined endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic biliary drainage. Tumor involvement of a creased papilla precluded endoscopic retrograde cholangiopancreatography (ERCP). EUS-cholangiography revealed a dilated common bile duct (CBD) and a patent cystic duct above a distal stricture (▶Fig. 1). EUS-choledochoduodenostomy was performed with an 8×8-mm lumen-apposing metal stent (LAMS). Bile and contrast outflow into the duodenum confirmed satisfactory placement of the LAMS (▶Video 1). The LAMS was balloon dilated prior to the intended insertion of an axis-orienting double-pigtail stent. However, during dilation, the distal flange of the LAMS dislodged from the CBD and guidewire access was lost. Duct decompression and aerobilia prevented repeat EUS-guided CBD puncture being performed. The gallbladder was imaged from the antrum and drained under EUS guidance with a cautery-enhanced 15×10-mm E-Videos