LAUSR

Electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) has been routinely used for endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) with high technical and clinical success [1]. One of the major factors that determines technical success is common bile duct (CBD) diameter. CBD size < 15mm is associated with a high risk of technical failure and maldeployment of the distal flange [2, 3]. Correct deployment of the distal flange inside the CBD is one of the most crucial steps of the procedure and, in cases of amarginally dilated duct, there is little space for opening of the distal flange, which increases the risk of maldeployment. Here, we describe a modified technique for deployment of the Hot-AXIOS stent (Boston Scientific, Marlborough, Massachusetts, USA) in such marginally dilated CBDs. Although stent deployment only requires a single operator and both locks (catheter lock and stent lock) should not be open simultaneously, in our technique we have modified both these aspects [4]. After puncturing the bile duct, initial deployment of the distal flange is performed as per the standard procedure. Once the distal flange has been deployed halfway, the assistant opens the catheter lock (at this step both locking systems are open) and gradually pushes the catheter more distally (which gives extra room for deployment of the distal flange), while the main operator simultaneously deploys the distal flange (▶Video 1). A 76-year-old woman who was diagnosed with locally advanced adenocarcinoma presented with acutemoderate cholangitis with prior failed ERC. EUS-CDS using EC-LAMS (Hot-Axios; 8 ×8mm) was planned. EUS-CDS was performed with a freehand technique using guidewire and a preloaded Hot AXIOS stent. As the CBD was marginally dilated (10.4mm), we used the technique described above for deployment of the distal flange, followed by intrachannel deployment of the proximal flange. Immediately after drainage, free flow of bile was observed. The patient improved after the procedure and was discharged after 24 hours. This technique ensures correct deployment of the distal flange, even in the presence of a marginally dilated CBD, resulting in technical success.