Endoscopy 2019; 51(09): E245-E246
DOI: 10.1055/a-0889-7329
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Transverse stent placement for hilar malignant biliary obstruction through an endoscopic ultrasound-guided hepaticogastrostomy route

Sachiko Kanai*
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Tomotaka Saito*
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Ryunosuke Hakuta
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Yousuke Nakai
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Kazuhiko Koike
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
› Author Affiliations
Further Information

Publication History

Publication Date:
09 May 2019 (online)

A 70-year-old woman who had undergone endoscopic placement of multiple stents for hilar biliary obstruction due to gallbladder cancer was admitted with cholangitis. In her previous hospitalization, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) had been performed for the bile duct at segment III (B3) using a partially covered self-expandable metal stent (SEMS; modified Giobor, 10 × 80 mm; Taewoong Medical Inc., Gimpo, Korea [1]). To manage subsequent episodes of cholangitis, two uncovered SEMSs were placed via the transpapillary route for B7 and B8 in a partial stent-in-stent fashion ([Fig. 1]). On this admission, endoscopic drainage was scheduled to manage segmental cholangitis in B8.

Zoom Image
Fig. 1 Radiographic view showing placement of uncovered metal stents in a partial stent-in-stent fashion following endoscopic ultrasound-guided hepaticogastrostomy.

In the first session, transpapillary biliary drainage of B8 failed as a cannula could not be passed through the mesh wall of the indwelling SEMS ([Fig. 2 a]). Therefore, we attempted to access B8 though the EUS-HGS stent. Using a side-viewing duodenoscope, we passed a guidewire into the ventral branch of B8 and dilated the mesh of the SEMS using a balloon catheter ([Fig. 2 b]). We then placed a nasobiliary catheter to manage the cholangitis. In the following session, we trimmed the gastric end of the EUS-HGS stent using argon plasma coagulation (ESG-100; Olympus, Tokyo, Japan) to facilitate insertion of the stent [2] and deployed an uncovered SEMS (Niti-S, 10 × 80 mm; Taewoong Medical Inc.) ([Fig. 2 c]; [Video 1]). There were no procedure-related adverse events.

Zoom Image
Fig. 2 Placement of a metal stent bridging a hilar malignant biliary stricture through an indwelling hepaticogastrostomy (HGS) stent after an unsuccessful transpapillary re-intervention. a During the transpapillary approach to B8, a cannula cannot be passed through the mesh wall of the indwelling SEMS. b Balloon dilation of a mesh interstice of the self-expandable metal stent (SEMS) is performed. c An uncovered SEMS is placed between B8 and B3 via the EUS-HGS route.

Video 1 Placement of a metal stent bridging a hilar malignant biliary stricture through an indwelling hepaticogastrostomy stent.


Quality:

Endoscopists occasionally face technical difficulties in managing occlusion of SEMSs placed for hilar biliary obstruction. The transpapillary approach is often used for re-intervention for the right-sided biliary system and, recently, the feasibility of EUS-guided hepaticoduodenostomy has been reported [3] [4]; however, both procedures are technically demanding. Furthermore, EUS-guided access to B8 is often anatomically impossible. Access to the right intrahepatic bile duct via the EUS-HGS route can offer an alternative strategy in this setting [5].

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* equal first authors