Novel double endoscopic ultrasound-guided hepaticogastrostomy for two-hole benign anastomotic stenosis with difficult gastrointestinal approach
Enteroscopy is useful for approaching anastomotic stenoses; however, in surgically altered anatomy, success rates of 70 % – 80 % have been reported . Alternatively, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) may be acceptable . Usually, one EUS-HGS is performed; however, double EUS-HGS is required for two-hole anastomotic stenosis to resolve symptoms. We report the first case of successful double EUS-HGS for two-hole benign anastomotic stenosis.
An 89-year-old woman had a history of right hepatic trisegmentectomy, and Roux-en-Y reconstruction for bile duct cancer 10 years prior to presentation. Percutaneous transhepatic biliary drainage (PTBD) was previously performed for B3 to treat cholangitis due to anastomotic stenosis, but cholangitis was poorly controlled because B2 and B3 were separately anastomosed. PTBD revealed that both had stenoses ([Fig. 1]). Endoscopic retrograde cholangiography was performed using double-balloon enteroscopy, but adhesion prevented the enteroscope from reaching the anastomosis. EUS-HGS was performed instead. Double EUS-HGS was temporarily applied to B2 and B3 using a laser cut-type fully covered metal stent (FCMS; 8 mm × 8 cm, X-suit NIR; Olympus, Tokyo, Japan) ([Fig. 2], [Video 1]). PTBD was removed during the same session. The stenoses were expanded 2 weeks after HGS fistula completion by placing another FCMS (8 mm × 5 cm, BONASTENT M-intraductal; Medicos Hirata, Tokyo, Japan) through the HGS fistula to both anastomoses. Plastic stents (7 Fr, 14 cm; Through Pass Type IT; Gadelius Medical, Tokyo, Japan) were placed at the HGS fistula ([Fig. 3]).
Video 1 Both B2 and B3 anastomoses had stenoses. First, double endoscopic ultrasound-guided hepaticogastrostomy was performed. Second, we deployed a fully covered metal stent to the anastomosis. All stents were removed 2 months later.
All stents were removed endoscopically from the HGS fistula 2 months later. Improvement of anastomotic stenosis was confirmed. Biopsy from the anastomosis revealed no malignant findings. No complications occurred during the procedure. No recurrence has been observed 5 months postoperatively. This is the first report on a successful double EUS-HGS, which can be safely performed for anastomotic stenosis with a two-hole anastomosis with difficult gastrointestinal approach.
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05 August 2020 (online)
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- 1 Skinner M, Popa D, Neumann H. et al. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 2014; 46: 560-572
- 2 Jovani M, Ichkhanian Y, Vosoughi K. et al. EUS-guided biliary drainage for postsurgical anatomy. Endosc Ultrasound 2019; 8 (Suppl. 01) S57-S66