Transorbital endoscopic ultrasonography (with video)

Abstract

A 31-year-old male presented with acute cholecystitis and history of metastatic alveolar rhabdomyosarcoma. He previously underwent left orbital exenteration and facial radiation. Given the patient's malnutrition, he was deemed a non-surgical candidate. The patient chose to pursue EUS-guided gallbladder drainage. Due to radiation-induced trismus, he was not able to open his mouth more than 5mm. Bougie dilation of an existing gastrostomy was considered, however there was concern for poor healing and gastrostomy leak. A discussion with his otolaryngologist revealed that because his left eye and surrounding bone were surgically removed, the left orbit gave direct access to the oropharynx. Therefore, transorbital intubation and endoscopy were pursued (A) (Video). Initially, neither the echoendoscope nor wire were able to intubate the esophagus antegrade due to radiation-associated scarring. A neonatal gastroscope was passed retrograde through the gastrostomy, up the esophagus, and into the orbit (B, C). A long 0.025-inch wire was passed and a forward-viewing echoendoscope was reinserted through the orbit over the wire. Esophageal intubation was successful by following a wire-guided balloon inflated to 13.5mm (D). An EUS-guided cholecystoduodenostomy was then performed. The patient tolerated the procedure well and discharged the day after without adverse events. The patient consented to publication.