Abstract
Endoscopic ultrasound-guided biliary drainage (EUS-BD) using lumen-apposing metal stents (LAMS) is an established approach for biliary access in patients with inaccessible ampullas or surgically altered anatomy. As recognized limitation of EUS-BD is stent dysfunction related to luminal solid debris, which may be particularly problematic in patients with impaired gastric emptying. We describe a novel technical modification involving partial closure of the proximal flange of a biliary LAMS using endoscopic suturing to reduce retrograde passage of solid luminal contents while preserving antegrade bile flow.
A 60-year-old female with a history of per-cholecystectomy bile duct injury requiring hepatico-duodenostomy presented with recurrent cholangitis over several years. Prior interventions included repeated ERCPs and placement of biliary LAMS with coaxial plastic stents, yet solid food debris was encountered within the biliary tree. During repeat intervention, an 8 mm * 6 mm LAMS was placed, followed by partial closure of the proximal flange using endoscopic suturing.
Liver chemistries normalized, and functional imaging demonstrated unrestricted biliary drainage, without evidence of retrograde solid food entry into the bile ducts.
This report illustrates a technical modification of biliary LAMS that may reduce solid luminal reflux. Further evaluation is required to define durability, safety, and broader applicability.