Novel simultaneous endoscopic ultrasound-guided hepaticoduodenostomy and hepaticogastrostomy for recurrent hepatic hilar obstruction
14 August 2018 (eFirst)
We present the case of a 46-year-old man who had undergone percutaneous side-by-side multi-stent drainage for hepatic hilar obstructive jaundice due to colorectal liver metastases ([Fig. 1]). Six months later, obstructive jaundice was again noted. Contrast-enhanced computed tomography (CT) revealed recurrent hilar obstruction due to tumor ingrowth into the stent.
As there were multiple liver metastases in the right anterior section, we decided to drain the left lobe and posterior section only. We opted for endoscopic ultrasound (EUS)-guided drainage because we anticipated that re-intervention via a trans-papillary approach would be difficult after triple side-by-side stenting ([Fig. 1]).
The EUS scope was inserted into the duodenal bulb where a dilated posterior branch (B6) could be identified ([Fig. 2]). The B6 branch was punctured using a 19-gauge needle, and a 0.025-inch guidewire was inserted after cholangiographic confirmation. Dilation of the tract was then performed using the ES-Dilator (Zeon Medical, Tokyo, Japan) and subsequently, an 8 mm × 6 cm fully covered self-expandable metal stent (SEMS-NIR stent; Olympus, Tokyo, Japan) was deployed. As the stent length at the duodenal side was slightly short, we inserted an additional stent of the same size into the existing stent. The EUS-guided hepaticoduodenostomy (HDS) was then complete ([Fig. 2], [Video 1]).
Video 1 Simultaneous endoscopic ultrasound-guided hepaticoduodenostomy and hepaticogastrostomy.
The EUS scope was then pulled back into the stomach where a hepaticogastrostomy (HGS) was performed to the B2 branch using a method similar to that described above ([Fig. 3]). [Fig. 4] shows the final fluoroscopic and CT images after simultaneous EUS-HDS and -HGS. There were no adverse events. Clinically, the total bilirubin level improved from 7.4 mg/dL to 0.9 mg/dL 14 days after the procedure. Chemotherapy was then restarted.
There are a few case reports of EUS-HDS in the literature    , but the current case is the first report of simultaneous left and right EUS drainage for hepatic hilar obstruction. It can be anticipated as a new drainage method.
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