Calculus-targeted puncture technique to overcome access difficulty during endoscopic ultrasound-guided hepaticogastrostomy

An 83-year-old woman was admitted to undergo endoscopic treatment for recurrent cholangitis caused by intrahepatic bile duct stones. Computed tomography revealed oval stones within the left intrahepatic bile ducts ([Fig. 1]). Stone removal via balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) was considered technically challenging owing to a history of three previous bile duct surgeries. Therefore, treatment with an endoscopic ultrasound (EUS)-guided technique was selected.

Fig. 1 Computed tomography image showing oval stones in the left intrahepatic bile ducts (white arrows).

Initially, EUS-guided hepaticogastrostomy (EUS-HGS) was performed via the B3 bile duct [Fig. 2] a); however, the hepatic parenchyma was extremely thin owing to repeated inflammation, making safe puncture and stent placement unfeasible. Although the B2 duct – dilated to approximately 4 mm – was subsequently targeted, puncture failed owing to its deep location and poor alignment with the needle trajectory.

Fig. 2 Images during endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) showing: a the initial attempt via the B3 bile duct (white arrow), which failed owing to the thin hepatic parenchyma that made safe puncture and stent placement unfeasible; b the echogenic calculus-targeted puncture being performed, using the intrahepatic stone (arrowheads) as the puncture target; c a dedicated plastic stent for EUS-HGS that was successfully deployed without adverse events.

Consequently, an echogenic calculus was selected as the puncture target ([Fig. 2] b). This novel technique significantly improved visualization and allowed for the establishment of a safer and more precise puncture route ([Video 1]). Access was successfully obtained using a 19-gauge needle, and a 0.025-inch guidewire was advanced smoothly through the B2 intrahepatic duct into the intestinal lumen beyond the stones. A second guidewire was inserted using a double-lumen cannula (Uneven Double Lumen Cannula; Piolax, Kanagawa, Japan), and this was followed by successful placement of a dedicated plastic stent for EUS-HGS (TYPE-IT stent, 7 Fr, 14 cm; Gadelius Medical, Tokyo, Japan) without any adverse events ([Fig. 2] c). Cholangioscopy-guided electrohydraulic lithotripsy performed 5 months later, after dilation of the endosonographically created route, achieved complete stone clearance ([Fig. 3]).

The calculus-targeted puncture technique is used during endoscopic ultrasound-guided hepaticogastrostomy, enabling cholangioscopy-guided lithotripsy and achieving complete removal of recurrent intrahepatic bile duct stones.Video 1

Fig. 3 Images during stone removal showing an intrahepatic bile duct stone (white arrows) with the lithotripter (arrowheads) positioned via the endosonographically created route to perform cholangioscopy-guided electrohydraulic lithotripsy on: a fluoroscopic image; b cholangioscopic image.

In cases where BE-ERCP is challenging owing to surgically altered anatomy, EUS-guided treatment has been reported as an effective approach for stone removal [1] [2] [3]. For patients with intrahepatic large bile duct stones and limited access routes, this novel calculus-targeted puncture technique may enhance visualization and improve puncture precision. Further studies are warranted to validate its safety and utility.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Iwashita T, Nakai Y, Hara K. et al. Endoscopic ultrasound-guided antegrade treatment of bile duct stone in patients with surgically altered anatomy: A multicenter retrospective cohort study. J Hepatobiliary Pancreat Sci 2016; 23: 227-233
• 2 Itoi T, Sofuni A, Tsuchiya T. et al. Endoscopic ultrasonography-guided transhepatic antegrade stone removal in patients with surgically altered anatomy: Case series and technical review (with videos). J Hepatobiliary Pancreat Sci 2014; 21: E86-E93
• 3 Ogura T, Kawai J, Nishiguchi K. et al. Transluminal intrahepaticbile duct stone removal using a novel spiral basket catheter via the endoscopic ultrasound-guided hepaticogastrostomy route (with video). Dig Endosc 2022; 34: 234-237

Publikationsverlauf

Artikel online veröffentlicht:
26. September 2025