Combined transpapillary drainage and endoscopic ultrasound-guided hepaticoduodenostomy after failed manipulation under cholangioscopy guidance
For unresectable malignant hilar biliary obstructions, drainage of ≥ 50 % of the liver volume is recommended . Endoscopic transpapillary biliary drainage is the current standard treatment for malignant hilar biliary obstruction. Cholangioscopy-assisted guidewire placement is a useful method for biliary drainage, which can be used even in patients without contrast-filled images 
In recent years, the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) for malignant hilar biliary obstruction has increasingly been reported. However, it is technically challenging, especially in patients with right intrahepatic bile duct (IHBD) obstruction. Herein, we report the use of combined conventional transpapillary drainage and EUS-guided hepaticoduodenostomy (EUS-HDS) in a patient with malignant hilar biliary obstruction after failed manipulation under cholangioscopy guidance.
A 46-year-old woman was diagnosed with malignant hilar biliary obstruction caused by unresectable pancreatic cancer, with metastasis affecting the left lobe of the liver ([Fig. 1]). For effective and precise biliary decompression, drainage of both the right anterior and posterior IHBDs was required; however, we were only able to insert the guidewire into the anterior IHBD. Because the cholangiogram showed complete obstruction, intraductal cholangioscopic guidance (SpyGlass DS system; Boston Scientific Corp., Natick, Massachusetts, USA) was used to access the posterior IHBD. Despite direct visualization of the bile duct, we could not access the posterior IHBD. Therefore, we subsequently used a linear echoendoscope and punctured the posterior IHBD through the duodenal wall, using a 19G needle (EZ Shot 3 Plus; Olympus Medical Systems, Tokyo, Japan). A 0.025-inch guidewire (VisiGlide 2; Olympus Medical Systems) was then placed, which allowed balloon dilation to 4 mm, and finally the successfully placement into the bile duct of a partially covered metal stent (Niti-S stent, 8 × 120 mm; Taewoong Medical, Seoul, Korea) to create an EUS-HDS ([Fig. 2]; [Video 1]).
Video 1 A single session of combined conventional transpapillary biliary drainage and endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS) in a patient with malignant hilar biliary obstruction (MHBO) after failed manipulation under cholangioscopy guidance.
For EUS-BD of the right-side of the liver, two main techniques have been described: direct puncture of the right-side of the liver from the bulbus (EUS-HDS), as first reported by Park et al. in 2013 , and a bridge technique that allows drainage of the right-side of the liver from the left via hepaticogastrostomy (the bridge technique) . In this case, the latter technique could not be applied because of the left-sided liver metastasis; the former was feasible, but only 13 further cases of the technique have been reported . In cases such as this, where we were unable to obtain a cholangiogram using a contrast agent, EUS-BD might be preferable because of its rapidity and cost-effectiveness. We would emphasize that, for technically demanding biliary drainage, there are alternatives to conventional transpapillary biliary drainage, including EUS-BD.
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