LAUSR

Use of the Tornus ES drill dilator (Asahi Intecc Co., Ltd., Aichi, Japan) has been reported for tract dilation in various settings [1–5]. While it has been used successfully in endoscopic ultrasound (EUS)-guided hepaticogastrostomy, tract dilation in EUS-guided choledochoduodenostomy (CDS) can be even more challenging [1–3]. The bile duct is visualized directly under the probe and the portal vein runs parallel on the other side, making large strokes dangerous. Extrahepatic bile ducts can be extremely stiff, particularly during conversion from conventional transpapillary stenting, precluding the insertion of mechanical or balloon dilators and requiring high-risk tract dilation using electrocautery. We report successful tract dilation in EUS-CDS using the Tornus ES dilator. A 55-year-old woman undergoing chemotherapy for metastatic pancreatic cancer presented with elevated transaminases. She had a history of severe pancreatitis following endoscopic retrograde cholangiopancreatography with placement of a biliary self-expandable metal stent, following which, 3 months prior to her current admission, a plastic stent had been placed for biliary drainage. She was diagnosed with recurrent biliary obstruction and EUS-CDS was planned (▶Video 1). A duodenoscope was inserted to remove the indwelling plastic stent and to inject contrast agent in the common bile duct. Converting to an endosonoscope, the common bile duct (diameter 12mm) was punctured with an EUS needle. The needle could not pierce the choledochal wall completely; however, a guidewire was successfully advanced into the bile duct. Injected contrast pooled near the puncture site and did not flow into the biliary tree (▶Fig. 1 a). ATornus ESwas therefore used to dilate the puncture route, which was achieved with ease with clockwise rotation of the dilator by the assistant (▶Fig. 1b, c). After additional dilation with a balloon dilator, the delivery system of the self-expandable metal stent adE-Videos