A 28-year-old female with a history of Roux-en-Y gastric bypass and colorectal liver
metastases underwent combined metastectomy and microwave ablation of segments 1, 2,
3, and 8. A postprocedural biloma was drained with a percutaneous drain, while percutaneous
transhepatic drain placement failed to treat the biliary leak. An EUS-guided gastro-gastrostomy
was created using a 20-mm cautery-enhanced lumen-apposing metal stent (LAMS) to facilitate
endoscopic retrograde cholangiopancreaticography (ERCP) with placement of biliary
plastic stents ([Video 1]). Both the percutaneous drain and the biliary stents clogged repeatedly due to the
large amount of necrotic contents, resulting in multiple infectious episodes. EUS-guided
drainage of the biloma was subsequently performed from the excluded stomach using
a 15 mm × 10 mm LAMS ([Fig. 1]). A double pigtail stent was placed through the LAMS to prevent stent migration
and dysfunction. The patient initially recovered but after 10 days again developed
stent dysfunction. During three endoscopic necrosectomy sessions, all necrotic tissue
in the biloma was removed using a snare and grasping forceps ([Fig. 2]). The LAMS was then exchanged for two plastic pigtails, and both the percutaneous
drain and biliary stents were removed. The patient recovered well, and a CT scan 3
months post-drainage showed only a small biloma remnant.
Endoscopic drainage and necrosectomy of a necrotizing biloma facilitated by endoscopic
ultrasound-guided gastro-gastrostomy.Video 1
Fig. 1 EUS-guided drainage of biloma from the excluded stomach using a 15-mm lumen-apposing
metal stent.
Fig. 2 Endoscopic view of the biloma cavity after necrosectomy.
In selected cases where standard therapy for symptomatic biloma – percutaneous drain
–
fails, EUS-guided transluminal biloma drainage may be performed, which in this patient
offered
several benefits. First, the challenges of surgically altered anatomy were overcome
by
EUS-guided gastro-gastrostomy, facilitating transgastric ERCP (EDGE) and other endoscopic
interventions (EDGI) [1]. Second, internal drainage of the biloma precluded the need for a percutaneous drain
and
improved the patient’s comfort [2]. Third, placement of a large caliber LAMS enabled necrosectomy that initiated clinical
recovery. Endoscopic necrosectomy has previously been shown to be effective in treating
necrotic
peripancreatic collections and gangrenous cholecystitis, with its potential applications
continuing to expand [3]
[4].
Endoscopy_UCTN_Code_TTT_1AS_2AJ
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
