Recently, endoscopic biliary and enteral stenting techniques, including the use of
endoscopic ultrasound (EUS), have been developed for patients with malignant biliary
obstruction (MBO) and malignant gastric outlet obstruction (GOO) [1 ]
[2 ]
[3 ]
[4 ]. However, when these conditions are encountered simultaneously, including during
reintervention, the use of this strategy remains controversial [5 ].
Herein, we report the case of a patient with recurrent MBO after biliary stenting
and concurrent GOO caused by biliary cancer, managed by EUS-guided hepaticogastrostomy
(HGS) and endoscopic enteral stenting using forward-viewing EUS (FV-EUS) in a single
session.
An 80-year-old man presented with pyrexia following chemotherapy for biliary cancer.
Contrast-enhanced computed tomography (CT) revealed intrahepatic bile duct dilatation
([Fig. 1 ]). The diagnosis was acute cholangitis due to stent dysfunction and progressive disease.
Emergency biliary drainage failed as the duodenoscope could not pass through the duodenal
stenosis caused by the invasive carcinoma. Given the patient’s age, limited life expectancy,
and the invasiveness of multiple sedation-requiring endoscopic procedures, we opted
for simultaneous EUS-HGS and enteral stenting.
Fig. 1 Contrast-enhanced computed tomography (CT) showing dilatation of the bilateral intrahepatic
bile duct (B2 branch, yellow arrowheads), a huge mass formed by biliary cancer and
metastatic lymph node (red arrowheads), biliary covered metallic stents placed side
by side (black arrowheads), and stenosis of the duodenum due to infiltration of the
tumor (green arrowheads). a Axial view, b oblique coronal view.
The dilated intrahepatic bile ducts were confirmed under EUS using FV-EUS (TGF-UC260J;
Olympus, Tokyo, Japan) and the left bile duct was punctured with a 19-gauge needle.
After injection of contrast medium, a 0.025-inch guidewire was placed. Following dilation
of the puncture site using a balloon dilator, the EUS-HGS stent was moved into position
over the guidewire under fluoroscopic guidance ([Fig. 2 ]
a–d ). Duodenal stenosis was confirmed endoscopically by means of FV-EUS. A guidewire
was advanced beyond the stenosis under fluoroscopic guidance to facilitate placement
of the enteral stent ([Fig. 2 ]
e–h ). Immediately postoperatively, CT confirmed appropriate placement of both the biliary
and the enteral stent ([Fig. 3 ]). The patient resumed oral intake without complications and was subsequently discharged
([Video 1 ]).
Fig. 2
a Forward-viewing endoscopic ultrasonography (FV-EUS) showing the left intrahepatic
bile duct (B2 branch, yellow arrowhead) slightly dilated and being punctured using
a 19-gauge needle (white arrowheads) under EUS guidance. b Fluoroscopic view showing confirmation of the B2 branch of the bile duct (yellow arrowhead)
injected with contrast medium. c Fluoroscopic view showing placement of the EUS-guided hepaticogastrostomy (HGS) stent
(yellow arrow). d Endoscopic view showing placement of the EUS-HGS stent into the stomach. e Conventional endoscopic view of FV-EUS showing the stenosis in the duodenal bulb and
placement of the guidewire through the stenosis. f Fluoroscopic view showing stenosis (white arrow) from the duodenal bulb to the descending
part after injection of contrast medium. g Fluoroscopic view showing placement of the enteral stent (green arrow) through the
duodenal stenosis. h Endoscopic view showing placement of the enteral stent through the duodenal stenosis.
Fig. 3 Axial CT immediately after EUS-HGS and enteral stenting: a, b EUS-HGS stent (yellow arrows) placed from the B2 branch of the bile duct to the stomach;
c, d enteral stent (green arrows) placed through the duodenal stenosis caused by the biliary
cancer with a metastatic lymph node.
Single-session endoscopic ultrasound-guided hepaticogastrostomy and enteral stenting
using forward-viewing endoscopic ultrasonography for malignant biliary and duodenal
stenosis.Video 1
This case underlines the potential efficacy of EUS-HGS and enteral stenting in a single
session using FV-EUS in high-risk patients, including older adults or those with multiple
comorbidities requiring concurrent GOO and MBO management, even in reintervention
scenarios. This approach minimizes the need for multiple sedation-requiring endoscopic
procedures.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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