Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) is an alternative
drainage method for malignant biliary obstruction (MBO) when endoscopic retrograde
cholangiopancreatography (ERCP) has failed [1]. A partially covered self-expandable metal stent (PCSEMS) is often used for EUS-HGS,
but it cannot be removed. A new metal or plastic stent is therefore placed as endoscopic
reintervention following EUS-HGS [2]
[3]
[4]; however, troubleshooting after endoscopic reintervention remains problematic because
of a paucity of reported cases.
An 81-year-old woman who had previously undergone ERCP for MBO due to pancreatic cancer
presented with recurrent biliary obstruction and duodenal stricture. An EUS-HGS using
a PCSEMS
(EGIS biliary stent, double-covered, 8 mm × 12 cm; S&G Biotech Inc., Yongin, South
Korea)
and duodenal stent placement were successfully performed. After 5 months, the patient
underwent
endoscopic reintervention for recurrent biliary obstruction. An additional fully covered
SEMS
(FCSEMS; HANAROSTENT benefit, 8 mm × 8 cm; Boston Scientific Co., Tokyo, Japan) was
deployed
through the stent mesh of the EUS-HGS PCSEMS because of the difficulty removing the
PCSEMS,
along with placement of an antegrade stent across the MBO ([Fig. 1]). A second endoscopic reintervention was required for SEMS occlusion, during which
new
plastic stents (Through & Pass Type-IT; Gadelius Medical, Tokyo, Japan) were placed
through
the distal end of the EUS-HGS SEMS after the stent mesh had been broken using argon
plasma
coagulation ([Fig. 2]).
Fig. 1 Fluoroscopic image showing endoscopic reintervention for recurrent biliary obstruction.
Because the partially covered self-expandable metal stent (PCSEMS) inserted for endoscopic
ultrasound-guided hepatogastrostomy (EUS-HGS) was not removed, an additional SEMS
(black arrow) was deployed through the stent mesh of the EUS-HGS PCSEMS, with an additional
antegrade stent placed across the malignant biliary obstruction (white arrow).
Fig. 2 During a second endoscopic reintervention for self-expandable metal stent occlusion,
new plastic stents were placed through the distal end of the endoscopic ultrasound-guided
hepatogastrostomy (EUS-HGS) self-expandable metal stent (SEMS), after the stent mesh
had been broken by argon plasma coagulation, because of the difficulty removing the
EUS-HGS SEMS.
After 2 months, the patient developed acute cholangitis due to migration of the EUS-HGS
SEMS placed during the first endoscopic reintervention and cholecystitis due to the
antegrade SEMS. After the plastic stents had been removed, grasping forceps (Rat Tooth;
Olympus, Tokyo, Japan) were inserted via the EUS-HGS SEMS. The migrated SEMS was grabbed
([Fig. 3]
a) and removed. Additionally, the antegrade SEMS was firmly grasped and gradually removed
via the EUS-HGS route ([Fig. 3]
b; [Video 1]). The successful removal of the two SEMSs was followed by the insertion of new plastic
stents and the patient’s cholangitis and cholecystitis subsequently improved.
Fig. 3 Fluoroscopic images showing: a the migrated self-expandable metal stent (SEMS) in the left intrahepatic bile duct
being grasped with grasping forceps and removed via the hepaticogastrostomy; b the antegrade SEMS in the common bile duct being grasped with grasping forceps and
gradually removed via the hepaticogastrostomy.
Endoscopic removal of a migrated self-expandable metal stent (SEMS) and antegrade
SEMS using grasping forceps via the hepaticogastrostomy route.Video 1
This technique demonstrates successful troubleshooting of endoscopic reintervention
after EUS-HGS.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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