ASIAN EUS CUP: Asian EUS Cup-03: Endoscopic ultrasound-guided biliary drainage with misplaced antegrade stent-repositioned with forceps through obstetric anal sphincter injuries

A 70-year-old woman presented with features of extrahepatic biliary obstruction. Evaluation was suggestive of a locally advanced carcinoma head of the pancreas. Endoscopic retrograde cholangiopancreatography was attempted for relief of cholestatic symptoms; however, the lumen of duodenum in the junction between its first and second part was narrowed. This hindered the passage of a side viewing endoscope. Standard forward viewing scope could be passed across and it showed a normal papilla. Endoscopic ultrasound-guided access of the bile duct was planned. The dilated intrahepatic biliary radicle was punctured from the stomach with a 19-gauge needle (Expect – Boston Scientific) and contrast injected. A 0.035 inch guidewire (Visiglide-Olympus Corp., Japan) was then negotiated across the papilla. Over the wire, dilatation of the stricture and the hepaticogastrostomy access point was done using a 4 mm biliary balloon (Hurricane Rx – Boston Scientific). Following this, a fully covered self-expandable metallic stents (WallFlex – Boston Scientific) was placed across the papilla. However, postdeployment, we noted that the proximal flange of the stent had not opened fully and was partly within the stricture segment. OASIS (10 Fr) (Cook Medical) was inserted over the wire inside the bile duct. The guiding catheter was removed and a forceps was inserted through the OASIS, a forceps was inserted. Using the forceps, gentle traction was deployed to pull the stent proximally. The technique illustrates risk of distal deployment of fully covered self-expandable metallic stents during antegrade stenting and the use of OASIS to pass a forceps for pulling the stent proximally.