Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a valuable alternative
for patients for whom endoscopic retrograde cholangiopancreatography (ERCP) is not
feasible. However, recurrent biliary obstruction occurs in approximately 19.1–33%
of cases, often necessitating reintervention [1]
[2]. Herein, we report a case of successful reintervention using peroral cholangioscopy
to treat biliary obstruction caused by tissue hyperplasia at the uncovered portion
of a self-expandable metallic stent (SEMS) placed during EUS-HGS ([Video 1]).
Reintervention using cholangioscopy for metallic stent obstruction following endoscopic
ultrasound-guided hepaticogastrostomy.Video 1
A 75-year-old man who underwent EUS-HGS for duodenal papillary carcinoma ([Fig. 1]) was diagnosed with acute cholangitis due to stent dysfunction. Reintervention was
attempted using the previously created endosonographic route.
Fig. 1
a Computed tomography (CT) image showing duodenal papillary carcinoma. b Magnetic resonance cholangiopancreatography (MRCP) showing a distal bile duct stricture.
c Gastroscopy showing duodenal stenosis due to duodenal papillary cancer. d A partially covered self-expandable metallic stent was placed on the B3 branch.
A dual-channel endoscope (GIF-2TQ260M, Olympus, Japan) was used to trim the SEMS.
The SEMS was grasped with forceps and trimmed via a secondary channel using argon
plasma coagulation ([Fig. 2]
a). Subsequently, contrast imaging was performed using a duodenoscope (TJF-Q290V, Olympus,
Japan), confirming complete stent obstruction ([Fig. 2]
b, c). Despite multiple attempts, a 0.025-in. angle-type guidewire could not be passed
through the obstructed site ([Fig. 2]
d).
Fig. 2 Reintervention using an endoscopic retrograde cholangiopancreatography (ERCP) catheter.
a The SEMS trimmed using argon plasma coagulation. b The ERCP catheter is inserted into the SEMS. c Cholangiography confirmed biliary obstruction. d Attempts at guidewire passage were unsuccessful.
Peroral cholangioscopy (Spyglass DS, Boston Scientific, Marlborough, USA) was advanced
through the SEMS, revealing complete obstruction of the uncovered segment by hyperplastic
tissue ([Fig. 3]
a, b). A 0.025-in. straight-type guidewire was successfully navigated into the common
bile duct under direct cholangioscopic visualization ([Fig. 4]
a, b). Balloon dilation of the obstructed site was then performed, followed by the placement
of a plastic stent across the obstruction ([Fig. 4]
c, d).
Fig. 3
a A cholangioscope introduced into the SEMS. b Uncovered segment of the SEMS is completely occluded by hyperplastic tissue.
Fig. 4 Reintervention using peroral cholangioscopy. a, b Guidewire passage was successfully performed under direct cholangioscopic visualization.
c Balloon dilation at the obstruction site. d Plastic stent placed in the bile duct.
Peroral cholangioscopy-guided reintervention for SEMS obstruction after EUS-HGS can
be an effective approach, particularly in cases where conventional guidewire passage
is challenging.
Endoscopy_UCTN_Code_TTT_1AS_2AH
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.
