Re-intervention with endoscopic ultrasound-guided hepaticogastrostomy for unresectable hilar biliary drainage using a multipath occlusion balloon
02 February 2018 (eFirst)
Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) and antegrade stenting (EUS-AS) have been developed as alternative biliary drainage methods; however, treating unresectable malignant hilar biliary strictures remains challenging   . We successfully performed re-intervention for malignant hilar biliary drainage after EUS-HGS using a multipath occlusion balloon.
A 46-year-old woman who was on medication for a postoperative recurrence of gastric cancer presented with jaundice. She had previously undergone double-balloon enteroscope (DBE)-assisted biliary drainage with a self-expandable metal stent (SEMS) for malignant biliary stricture of the lower bile duct.
Contrast-enhanced computed tomography (CT) showed strictures of the hilar bile duct and duodenum ([Fig. 1]) associated with dissemination of the gastric cancer. EUS-HGS was performed ([Fig. 2]), and a 7-Fr plastic stent (TYPE-IT; Gadelius Medical, Tokyo, Japan) was placed into the B3 bile duct . However, the patient’s jaundice was not improved, and re-intervention was required. A 0.025-inch guidewire was placed into the duodenum beyond the papilla, and the plastic stent was removed. A second 0.025-inch guidewire was placed into the B5 bile duct using a multipath occlusion balloon (Bouncer; Cook Medical, Tokyo, Japan) ([Fig. 3]). This balloon has a multilumen located at either end of the balloon, which enables guidewires to be passed easily into crooked bile ducts ([Fig. 3] and [Fig. 4 a]; [Video 1]). A Zilver 635 biliary SEMS (Cook Medical, Tokyo, Japan) was introduced over the first guidewire and placed into the B5 bile duct, bridging the right and left hepatic ducts ([Fig. 4 b]). Finally, a modified Niti-S GIOBOR biliary stent (Century Medical, Tokyo, Japan) was placed into the B3 bile duct ([Fig. 4 c]). The jaundice subsequently improved, and no adverse events occurred.
Video 1 Re-intervention with endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). Drainage of the right hepatic duct was challenging, but we achieved technical success using a multipath occlusion balloon.
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