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.
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.
Endoscopy_UCTN_Code_TTT_1AS_2AH
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