Endoscopic ultrasound-guided choledochoduodenostomy as a life-saving salvage therapy for post-transplant acute biliary obstruction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a recognized and effective alternative to conventional retrograde biliary drainage methods, such as endoscopic retrograde cholangiopancreatography (ERCP [ 1 ] [ 2 ]). While endoscopic ultrasound (EUS) is occasionally employed for diagnosing complications following liver transplantation, the feasibility of EUS-guided interventions for managing post-transplant complications has been documented in only a limited number of case reports [ 3 ] [ 4 ] [ 5 ]. We report the first case in which endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was successfully utilized as an emergency intervention in a liver transplant recipient with septic shock, following the failure of ERCP. We report the case of a 61-year-old man who developed cholestatic jaundice and pruritus 1 year after orthotopic liver transplantation. Magnetic resonance cholangiopancreatography revealed a hilar biliary stricture. The patient underwent percutaneous transhepatic cholangiography drainage; however, catheter migration led to inadequate biliary drainage and persistent jaundice. Subsequent ERCP included the placement of a pancreatic duct stent but failed to relieve the biliary obstruction ([ Fig. 1 ] a ). The patient rapidly progressed to septic shock following the procedure. After fluid resuscitation and vasopressor support, EUS-CDS was performed. An 8 mm × 6 mm self-expandable metal stent was deployed between the dilated common bile duct and the duodenal bulb, and an 8.5-Fr naso-biliary catheter was inserted into the bile duct to enable continuous irrigation ([ Video 1 ], [ Fig. 1 ] b–d ). Fig. 1 Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) for post-transplant biliary obstruction. a Endoscopic retrograde cholangiopancreatography (ERCP) failed to place a biliary stent; however, a pancreatic duct stent was placed successfully. b and c EUS-CDS with successful stent deployment. d A naso-biliary catheter was placed in the bile duct through the stent, and fluoroscopy confirmed the absence of leakage. Download Video Procedure of endoscopic ultrasound-guided choledochoduodenostomy using a self-expandable metal stent.Video 1 Within 72 hours following the procedure, procalcitonin fell from >100 ng/mL to 12.7 µmol/L, and C-reactive protein decreased from 122.4 to 20.3 mg/L. Haemodynamic stability was restored, and vasopressors were weaned off. The patient was discharged home in stable condition 2 weeks postoperatively. To the best of our knowledge, this case represents the first reported instance in which EUS-CDS can serve as a life-saving and minimally invasive rescue therapy for septic biliary obstruction when both conventional ERCP and percutaneous approaches have failed in a post-liver transplant patient. This finding may broaden the indications for EUS-BD in post-surgical patients with altered anatomy and life-threatening sepsis, establishing it as a viable emergent therapeutic option. Endoscopy_UCTN_Code_TTT_1AS_2AD Publication History Article published online: 08 January 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany