Endoscopic ultrasonography-guided hepaticoduodenostomy (EUS-HDS) is an effective treatment
for biliary obstruction of the posterior branch; however, inserting the stent delivery
system can be challenging in cases with an acute angle to the bile duct [1 ]
[2 ]
[3 ]
[4 ]
[5 ]. A novel partially covered self-expandable metallic stent (Niti-S EUS-BD system
End Bare Single Flare; Taewoong Medical Co., Ltd.) with an ultra-tapered tip specifically
designed for a 0.025-inch guidewire and 7-Fr slim delivery system facilitates transluminal
stent insertion. Herein, we report a challenging case of EUS-HDS using the novel 7-Fr
Niti-S stent ([Video 1 ]).
Endoscopic ultrasonography-guided hepaticoduodenostomy was successfully performed
using a novel self-expandable metallic stent with an ultra-tapered tip and a 7-Fr
slim delivery.Video 1
A 61-year-old woman with huge liver metastases of colon cancer was admitted due to
hilar biliary obstruction. The intrahepatic bile duct was separately obstructed as
Bismuth type IV. Initially, endoscopic ultrasonography-guided hepaticogastrostomy
was performed; however, jaundice did not improve sufficiently ([Fig. 1 ]). Due to the presence of ascites around the right liver lobe, EUS-HDS was attempted
as an alternative to percutaneous drainage ([Fig. 2 ]). The right posterior branch was punctured using a 19-gauge needle. High resistance
was felt during puncture because the Glisson sheath was penetrated ([Fig. 3 ]). After the insertion of a 0.025-inch guidewire (VisiGlide 2; Olympus medical systems),
an ultra-tapered catheter could not pass through the bile duct wall. Although a 7-Fr
mechanical dilator (ES dilator soft type; Zeon Medical) was inserted into the posterior
branch, the catheter still failed to advance. Subsequently, the novel 7-Fr Niti-S
stent was attempted to insert into the bile duct. The ultra-tapered tip of the slim-delivery
system easily advanced across the bile duct wall, and the 8-mm and 10-cm stent was
successfully placed. Cholangiography confirmed no bile leakage into the abdominal
cavity ([Fig. 4 ]).
Fig. 1 A novel 7-Fr Niti-S EUS-BD system End Bare Single Flare.
Fig. 2 A computed tomography image after endoscopic ultrasonography-guided hepaticogastrostomy
shows ascites and dilated posterior branches (arrowhead).
Fig. 3 Ultrasound images during the procedure. a A 19-gauge needle
penetrates the Glisson sheath around the bile duct (arrowhead). b A
7-Fr slim-delivery system of the novel Niti-S stent passes through the bile duct
wall.
Fig. 4 Fluoroscopic images during the procedure. a The posterior branch is punctured, and a guidewire is inserted into the bile duct.
b An ultra-tapered catheter fails to advance after dilation. c The novel 7-Fr Niti-S stent can be inserted into the bile duct. d The stent is successfully deployed to the duodenum.
To the best of our knowledge, this is the first report of successful EUS-HDS using
the novel 7-Fr Niti-S stent with an ultra-tapered tip and a slim-delivery system.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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