Endoscopic ultrasound-guided biliary drainage using a novel visibility enhancement mode of a fluoroscopic system

Interventional endoscopic ultrasound (EUS) including EUS-guided biliary drainage (EUS-BD) has been indicated for failed endoscopic retrograde cholangiopancreatography (ERCP). The technical steps can be divided into four: bile duct puncture, guidewire insertion, tract dilation, and stent deployment [1] [2] [3]. During EUS-BD, a 0.025-inch guidewire is mainly used. In addition, fine-gauge devices such as a dilation device [4] or a stent delivery system [5] have been developed. However, these devices might provide poor visibility with contrast medium injection, especially EUS-guided hepaticogastrostomy (HGS). To improve the fluoroscopic visibility of these devices, a novel visibility enhancement mode of a fluoroscopic system (Astorex i9; Canon Medical Systems, Kanagawa, Japan), called Accent mode, has become available. Technical tips for EUS-HGS using Accent mode are presented.

A 77-year-old man was admitted to our hospital due to obstructive jaundice caused by cancer of the head of the pancreas. Biliary drainage was previously tried under ERCP guidance, but because of tumor invasion into the duodenum, EUS-HGS was attempted. The intrahepatic bile duct was punctured using a 19G needle, and the contrast medium was injected ([Fig. 1]). Then, insertion of a 0.025-inch guidewire (VisiGlide; Olympus Medical, Tokyo, Japan) through the needle was attempted ([Fig. 2]). However, on cholangiography, several bile duct branches were observed, and the visibility of the guidewire was inadequate. In this situation, if the guidewire were inserted into the bile duct branches, the visibility of the guidewire might be decreased. Therefore, we switched into Accent mode ([Fig. 3]), thereby increasing the visibility of the guidewire. After successful guidewire deployment, a fine-gauge stent delivery system (5.9-Fr, Hanarostent Benefit; M.I. Tech, Seoul, S. Korea), whose visibility on fluoroscopic imaging was poor, was inserted. However, the distal end of the stent was clearly identified ([Fig. 4]), and EUS-HGS was finally successful without any adverse events and the patient was discharged after 5 days ([Fig. 5] , [Video 1]).

Fig. 1 The intrahepatic bile duct is punctured using a 19G needle.

Fig. 2 Insertion of a 0.025-inch guidewire is attempted, but the visibility of guidewire is inadequate.

Fig. 3 Accent mode improves the visibility of the guidewire.

Fig. 4 Stent release is attempted with adequate visibility.

Fig. 5 Stent deployment from the intrahepatic bile duct to the stomach is successfully performed.

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Stent deployment is performed using Accent mode.Video 1

In conclusion, a novel visibility enhancement mode of a fluoroscopic system might be useful during EUS-BD, especially when using fine-gauge devices.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

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• 3 Kamal F, Khan MA, Lee-Smith W. et al. Efficacy and safety of EUS-guided biliary drainage for benign biliary obstruction – A systematic review and meta-analysis. Endosc Ultrasound 2023; 12: 228-236
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• 5 Ogura T, Ueno S, Okuda A. et al. Technical feasibility and safety of one-step deployment of EUS-guided hepaticogastrostomy using an 8-mm diameter metal stent with a fine-gauge stent delivery system (with video). Endosc Ultrasound 2021; 10: 355-360

Publication History

Article published online:
02 October 2024