A simple replacement method for a 7 Fr dedicated plastic stent in endoscopic ultrasound-guided hepaticogastrostomy

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is expected to become widespread in the future [1]. A 7 Fr dedicated plastic stent (Through and Pass, TYPE‐IT; Gadelius Medical Co. Ltd., Tokyo, Japan) ([Fig. 1]) is often used to prevent serious adverse events, such as migration or obstruction of bile duct branches [2] [3]. However, this stent has a pigtail structure on the stomach side, making it difficult to place a guidewire through the stent. Furthermore, inserting a guidewire into the side of the stent is associated with strong frictional resistance and may result in placement intraperitoneally. When removing the stent with grasping forceps, the tube may be left in the liver as it is readily fractured ([Fig. 2]). This case demonstrates a method we devised for inserting a guidewire into a dedicated plastic stent for easy removal.

Fig. 1 The 7 Fr dedicated plastic stent.

Fig. 2 Endoscopic images of stent removal attempt. a The stent is grasped by forceps for removal. b The stent is left behind in the liver following fracture during the removal attempt.

A 75-year-old woman developed cholangitis from perihilar cholangiocarcinoma, which was not controlled with multiple transpapillary stents. EUS-HGS was performed, and after creation of the gastrobiliary fistula, the plastic stent was replaced with a metal stent.

For stent replacement, we inserted the guidewire into a 3.5 Fr catheter (PR-110Q-1; Olympus Medical Systems, Tokyo, Japan), which was grasped by a snare (SD-8P-1, Olympus) ([Fig. 3]). We used a side-viewing duodenoscope (TJF 260; Olympus) and inserted the cannulated guidewire on the pigtail side ([Video 1]). After guiding through the loop of the pigtail, the snare was opened, the distal end of the plastic stent was grasped ([Fig. 4]), and the stent was pulled into the scope for straightening. Then, the guidewire was inserted into the bile duct and the stent was removed by pulling the snare. A cholangiogram was performed and the covered metal stent was placed.

Fig. 3 Method for stent removal. a The 3.5 Fr catheter (above) and snare (middle); a disposable electrosurgical snare (SD-221L-25; Olympus, Tokyo, Japan) can be used as a substitute (below). b The 3.5 Fr catheter grasped by the snare.

Video 1 Easy replacement method for a 7 Fr dedicated plastic stent in endoscopic ultrasound-guided hepaticogastrostomy.

Fig. 4 The guidewire was inserted into the loop of the pigtail, and the snare grasped the plastic distal end.

This method enables the guidewire to be reliably placed in the bile duct, enabling safe exchange of a dedicated plastic stent.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Ogura T, Higuchi K. Technical tips for endoscopic ultrasound-guided hepaticogastrostomy. World J Gastroenterol 2016; 22: 3945-3951
• 2 Itoi T, Sofuni A, Tsuchiya T. et al. Initial evaluation of a new plastic pancreatic duct stent for endoscopic ultrasonography-guided placement. Endoscopy 2015; 47: 462-465
• 3 Ochiai K, Fujisawa T, Ishii S. et al. Risk factors for stent migration into the abdominal cavity after endoscopic ultrasound-guided hepaticogastrostomy. J Clin Med 2021; 10: 3111

Publication History

Article published online:
26 May 2023