Endoscopic ultrasound—directed transduodenal endoscopic retrograde cholangiopancreatography in a patient with a duodenal switch for complex stone management

Background and Aims: A 69-year-old male patient with a previous duodenal switch surgery presented with choledocholithiasis and cholangitis. Initially, interventional radiology (IR) performed biliary stent placement with a metal stent left in situ. One year later, the patient presented again with cholangitis, now requiring definitive treatment via EUS-directed transduodenal ERCP (EDDE). Methods: An anastomosis was created between the first portion (superior portion) of the duodenum (D1) and the excluded second portion (descending portion) of the duodenum (D2) using a lumen-apposing metal stent (LAMS). After anastomosis maturation, the patient returned for ERCP and removal of the IR-placed stent. The previously placed stent initially could not be removed, so a metal stent was placed within the IR-placed stent for later removal via stent-in-stent technique. Three months later, the stents were removed, and the bile duct was swept with a balloon. Stones and debris were extracted from the duct. The duodenoduodenal LAMS was removed, leaving a patent fistula in place. Results: An EDDE was successfully performed between the D1 and D2 portions of the duodenal switch. The patient was asymptomatic and stent-free. Conclusions: The successful completion of this procedure indicates that it may be safe and effective to perform an EDDE in patients with duodenal switch anatomy.