Endoscopy 2022; 54(05): E207-E209
DOI: 10.1055/a-1486-6510
E-Videos

Conversion of endoscopic ultrasound-guided hepaticogastrostomy to transpapillary drainage by anterograde intervention via dedicated biliary metal stent for benign biliary stenosis

Antonio Martinez-Ortega
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
2   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitario Ramon y Cajal, Madrid
,
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
Sergio Bazaga
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
Julio G. Velasquez-Rodriguez
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
Sandra Maisterra
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
3   Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Catalonia, Spain
› Author Affiliations

An 80-year-old woman with obstructive jaundice caused by distal biliary stenosis secondary to chronic pancreatitis was referred for biliary drainage. After failed endoscopic retrograde cholangiopancreatography, endoscopic ultrasound (EUS)-guided biliary drainage was proposed. Portal cavernomatosis prevented an extrahepatic route and EUS-hepaticogastrostomy (HGS) was considered.

Using a linear echoendoscope, the left biliary duct was accessed with a 19‑gauge needle. The tract diameter was increased using a 6-Fr cystotome and 4-mm balloon catheter. A partially covered biliary self-expandable metal stent (SEMS; 8 × 80 mm Niti-S Giobor stent; Taewoong Medical, Goyang-si, South Korea) was placed ([Fig. 1]).

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Fig. 1 Endoscopic ultrasound (EUS)-guided hepaticogastrostomy. a Dilation of the transmural fistula under fluoroscopic guidance. b Endosonography image of intrahepatic duct and guidewire. c, d Placement of dedicated biliary metal stent (8 × 80 mm; 70 % covered, 30 % bare; Niti-S Giobor Biliary stent; Taewoong Medical, Goyang-si, South Korea) by fluoroscopic (c) and EUS (d) guidance.

Endoscopic anterograde transhepatic intervention was attempted 6 weeks later through the mature EUS-HGS fistula. Anterograde cholangioscopy using a pediatric scope through the transhepatic SEMS showed tissue ingrowth at the uncovered end (2.4 cm), occluding the distal stent lumen. The Giobor stent was removed using a grasping forceps after maximal intrastent balloon dilation ([Fig. 2]). The fistula tract was explored by anterograde cholangioscopy, identifying intrahepatic ducts close to the gastric wall. Scope exchange to a therapeutic scope allowed cholangiography using an impacted balloon extractor, and a biliary roadmap was captured. Next, a plastic stent (8.5 Fr × 9 cm) was placed across the HGS fistula to secure guidewire passage in the desired anterograde transpapillary direction. The extrahepatic duct was then successfully cannulated using the wire-guided fluoroscopy technique, and a sphincterotome was advanced across the distal stenosis to the duodenal lumen. Finally, biliary dilation up to 8 mm and anterograde stenting (fully covered SEMS; 10 × 80 mm Wallflex; Boston Scientific Corp., Marlborough, Massachusetts, USA) guided by fluoroscopy was performed ([Fig. 3], [Video 1]).

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Fig. 2 Maximal intrastent dilation up to 8 and 10 mm of the distal bare portion (Giobor stent) by fluoroscopic guidance. a, c Fluoroscopic images; b endoscopic image.
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Fig. 3 Endoscopic transhepatic anterograde intervention. a Balloon catheter and plastic stent within the mature hepaticogastrostomy fistula. b Anterograde dilation of extrahepatic distal biliary stenosis up to 8 mm, guided by fluoroscopy.

Video 1 Conversion of endoscopic ultrasound-guided hepaticogastrostomy to transpapillary drainage by anterograde intervention using a dedicated biliary metal stent in a benign distal biliary stenosis.


Quality:

The Giobor stent is a dedicated biliary stent for HGS and has been reported for use in malignant diseases but not as a temporary stent [1] [2] [3] [4] [5]. The recent change in covered design (70 %:30 %) enables its use in a biliary benign scenario as a temporary stent to create a transhepatic mature fistula, allowing subsequent anterograde stenting.

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Publication History

Publication Date:
12 May 2021 (online)

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