During endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), manipulation of
the guidewire is one of the most challenging steps, and guidewire-related bile duct
perforation is a potential adverse event [1]
[2]. When a bile duct perforation does occur, there is no established consensus on management,
and repeat puncture is frequently required. The liver impaction technique, first described
by Ogura et al., involves withdrawing the puncture needle into the liver parenchyma
to prevent guidewire kinking or shearing [3]. This maneuver enables redirection of a guidewire that has entered a peripheral
bile duct toward the central duct [4]. We report a case of bile duct perforation that was successfully managed using the
liver impaction technique.
The patient was a 90-year-old man with obstructive jaundice due to unresectable pancreatic
head cancer. Transpapillary biliary drainage was unsuccessful, and EUS-HGS was performed.
Using a convex-array echoendoscope, the B3 intrahepatic bile duct (3 mm) was punctured
transgastrically with a 19-gauge needle. The bile duct was small and its lumen was
easily collapsed during puncture. Cholangiography confirmed entry into the bile duct,
and a 0.025-inch angled guidewire was inserted. However, the wire perforated the bile
duct and was misplaced outside the bile duct ([Fig. 1]).
Fig. 1 The guidewire perforated the bile duct and was misplaced outside the bile duct during
endoscopic ultrasound-guided hepaticogastrostomy.
The puncture needle was then withdrawn into the liver parenchyma. This maneuver restored
the collapsed lumen on ultrasound and improved guidewire maneuverability. The guidewire
was successfully redirected and advanced into the common bile duct. After catheter
insertion, about 30 mL of bile was aspirated. Balloon dilation (3 mm) was performed,
followed by placement of a 7-Fr dedicated plastic stent ([Video 1]). The procedure was completed without adverse events, and the patient’s jaundice
improved.
Troubleshooting guidewire perforation of the bile duct during endoscopic ultrasound-guided
hepaticogastrostomy using the liver impaction technique.Video 1
In small bile ducts, the lumen often collapses during puncture, increasing the risk
of guidewire-related perforation. The liver impaction technique improves guidewire
maneuverability and maintains duct patency, making it a useful option for managing
guidewire perforation during EUS-HGS.
Endoscopy_UCTN_Code_CPL_1AL_2AD
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