A 58-year-old male with no significant personal or familial medical history was admitted with abdominal pain and distension. A submaxillary lymph-node biopsy led to the diagnosis of follicular NHL (grade I-II, phase IV). He reported having dark (tea color) urine and yellowish discoloration of the facial skin and sclera that gradually spread to the whole body. He also complained of persistent abdominal distension, abdominal pain, fatigue, and decreased appetite. Physical examination showed that he had a chronic disease appearance with jaundice of the skin and sclera, and soybean-sized lymph nodes were palpable in the left submandibular region. These enlarged lymph nodes were hard, without significant tenderness, and had poor mobility. Abdominal examination revealed distended abdomen. Multiple masses of different sizes can be touched in the entire abdomen, including the left lower abdomen, with a palpable 15 cm * 20 cm mass with clear boundaries, hard quality, and mild tenderness. Abnormal hepatic function was detected: the patient's alanine aminotransferase (ALT) level was 330 U/L, aspartate aminotransferase (AST) level was 353 U/L, total bilirubin (TBIL) level was 40.33 mumol/L, and direct bilirubin (DBIL) level was 24.21 mumol/L. The patient was treated with medication to protect the liver and decrease the enzyme levels and jaundice, but the jaundice continued to worsen; a hepatic function test performed revealed an ALT level of 168 U/L, AST level of 323 U/L, and TBIL level of 361 mumol/L. Magnetic resonance imaging and computed tomography of the abdomen both revealed numerous filling lymphomatous lesions in the abdominal cavity (Figure 1A), and magnetic resonance cholangiopancreatography showed external pressure stenosis in the middle segment of the common bile duct, expansion of the intrahepatic bile duct, and beak-like expansion of the intrahepatic bile duct (Figure 1B).
With continued worsening, relief of the obstructive jaundice by puncture drainage was urgently needed to ensure the success of subsequent chemotherapy. ERCP was performed, but failed because of the infiltration of lymphoma into the duodenal bulb, which resulted in narrowing of the descending junction (Figure 1C). Percutaneous transhepatic cholangio-drainage was not performed due to the patient's poor coagulation and the expansion of the right hepatic duct. The patient's jaundice continued to worsen; a hepatic function test performed revealed an ALT level of 211 U/L, AST level of 301 U/L, TBIL level of 485.6 mumol/L, and DBIL level of 340.2 mumol/L. Therefore, EUS-BD was selected as a workable drainage method, and the patient provided informed consent to undergo the procedure. So, EUS-guided transgastric anterograde common bile duct stenting was performed under general anesthesia (Figure 2, Supplementary Video S1). The duration of this operation was about half an hour.