One-step primary endoscopic ultrasound-guided choledochoduodenostomy without lumen-apposing metal stent using a Franseen needle and an ultra-stiff high-sliding guidewire

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) using a lumen-apposing metal stent (LAMS) can be used as a primary treatment for malignant distal biliary obstruction because of its higher technical success rates and shorter procedure times than conventional transpapillary metal stent placement [1] [2]. However, it is unsuitable for minimally dilated common bile ducts (CBDs) and thin 6-mm-diameter LAMSs are commonly used owing to large flanges. Other disadvantages include high costs, early stent dysfunction, and adverse events caused by biliary wall compression, duodenobiliary reflux, and cautery puncture [3]. Conversely, EUS-CDS with conventional metal stents requires a fistula dilation step that is time-consuming, leading to biliary peritonitis and a high risk of stent migration. Therefore, we propose a novel one-step EUS-CDS method without a LAMS using a Franseen needle and an ultra-stiff, high-sliding guidewire.