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

Sep 30, 2026

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was used as an emergency rescue intervention in a liver transplant recipient with septic shock when conventional retrograde drainage failed and percutaneous biliary drainage proved inadequate. After ERCP could not relieve the biliary obstruction, the patient deteriorated rapidly. Following stabilization with fluids and vasopressors, an 8mm×6mm self-expandable metal stent and a naso-biliary catheter enabled continuous irrigation, leading to prompt biomarker improvement and successful weaning of vasopressors, with discharge at two weeks.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Background

Case presentation

Initial transplant complication and failed ERCP

Progression to septic shock

Rescue intervention: EUS-CDS procedure

Stent deployment and naso-biliary irrigation

Outcomes and clinical follow-up

Authors and declarations

Article published online: 2026-01-08 Endoscopic ultrasound-guided choledochoduodenostomyas a life-saving salvage therapy for post-transplant acute biliary obstruction Video 1 Procedure of endoscopic ultrasound-guided choledochoduodenostomy using a self-expandable metalstent. 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 [3–5] . 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 ahilar biliary stricture. The patient under- ▶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. went 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.1a) . The patient rapidly progressed to septic shock following the procedure. After fluid resuscitation and vasopressor support, EUS-CDS was performed. An 8mm×6mm 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) . Within 72 hours following the procedure, procalcitonin fell from >100ng/mL to 12.7µmol/L, and C-reactive protein decreased from 122.4 to 20.3mg/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 Song Yiran et al. Endoscopic ultrasound-guided choledochoduodenostomy… Endoscopy 2026; 58: E7–E8 | © 2026. The Author(s) . E7 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 Contributors ʼ Statement Yiran Song: Writing – original draft, Writing – review & editing. Bixiong Zhang: Data curation, Investigation, Supervision, Validation. Yue Sun: Data curation, Methodology, Validation. Yue Li: Conceptualization, Methodology, Resources, Supervision. Conflict of Interest The authors declare that they have no conflict of interest. The authors | Yiran Song1, Bixiong Zhang2, Yue Sun2, Yue Li2
1 Department of Gastroenterology, The Affiliated Taizhou People ʼ s Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, China
2 Endoscopy Center, Guangdong Provincial People ʼ s Hospital, Guangdong Academy

FAQs

Why was EUS-guided choledochoduodenostomy chosen in this case?

EUS-CDS was selected because ERCP failed to relieve post-transplant biliary obstruction and percutaneous drainage became inadequate due to catheter migration.

What was placed during the EUS-CDS procedure?

An 8mm×6mm self-expandable metal stent was deployed between the dilated common bile duct and the duodenal bulb, followed by placement of an 8.5-Fr naso-biliary catheter for continuous irrigation.

What clinical improvements were observed after EUS-CDS?

Within 72 hours, procalcitonin and C-reactive protein levels decreased substantially, hemodynamic stability returned, vasopressors were weaned, and the patient was discharged in stable condition two weeks postoperatively.

Sep 30, 2026

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