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CC BY 4.0 · Endoscopy 2025; 57(S 01): E1128-E1129
DOI: 10.1055/a-2707-3324
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Pitfall of endoscopic ultrasound-guided hepaticoduodenostomy: Impact of hepatic parenchymal volume during device insertion

Authors

  • Takeshi Ogura

    1   Endoscopy Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan (Ringgold ID: RIN38588)
    2   2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan (Ringgold ID: RIN13010)

  • Jun Matsuno 

    2   2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan (Ringgold ID: RIN13010)

  • Takafumi Kanadani

    2   2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan (Ringgold ID: RIN13010)

  • Junichi Nakamura

    2   2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan (Ringgold ID: RIN13010)

  • Hiroki Nishikawa

    2   2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan (Ringgold ID: RIN13010)
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Endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS) can be indicated for isolated right hepatic duct obstruction after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) [1] [2]. Although this technique has clinical impact on selected patients, the technical aspects are not yet established because there are few indications for EUS-HDS itself. Compared with EUS-guided hepaticogastrostomy (HGS), pushing force may be transmitted less effectively to the bile duct, and pushback can occur during device insertion. During EUS-HGS, increasing the angle of EUS can increase the pushing force. During EUS-HDS, however, increasing the angle reduces pushback less effectively. To increase the pushing force, hepatic parenchyma volume might be important as a greater volume may reinforce the pushing force. We herein describe a pitfall of EUS-HDS during stent delivery system insertion.

After inserting the echoendoscope into the duodenum, the right hepatic bile duct was identified. Superficial intrahepatic bile duct puncture was performed using a 19G needle, and contrast medium was injected ([Fig. 1]). After successful guidewire deployment, ERCP catheter insertion was attempted but was unsuccessful because the pushing force deflected to the right side ([Fig. 2]). Therefore, tract dilation was performed using a drill dilator ([Fig. 3]). Attempted insertion of a stent delivery system (5.9 Fr, HANARO Benefit; Boston Scientific, Marlborough, Massachusetts) into the biliary tract failed for the same reason ([Fig. 4]). We then performed the double-guidewire technique to fit the axis and improve pushing ability, which enabled insertion of the stent delivery system and subsequent stent deployment ([Fig. 5], [Video 1]). As free air was observed after the procedure, the patient was placed under conservative treatment for four days.

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Fig. 1 Cholangiography confirms the superficial right hepatic duct puncture.
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Fig. 2 During endoscopic retrograde cholangiopancreatography catheter insertion, the pushing force deflects to the right side (arrow).
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Fig. 3 Tract dilation is performed using the drill dilator.
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Fig. 4 Insertion of the stent delivery system failed due to the pushing force deflecting to the right side (arrow).
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Fig. 5 Successful stent deployment after employing the double-guidewire technique.
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Insertion of the stent delivery system failed due to the pushing force deflecting to the right side.Video 1

In conclusion, choosing a puncture route across a large enough hepatic parenchyma volume may enable successful device insertion during EUS-HDS.

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Conflict of Interest

The authors declare that they have no conflict of interest.

  • References

  • 1 Ma KW, So H, Cho DH. et al. Durability and outcome of endoscopic ultrasound-guided hepaticoduodenostomy using a fully covered metal stent for segregated right intrahepatic duct dilatation. J Gastroenterol Hepatol 2020; 35: 1753-1760
    CrossrefPubMedSearch in Google Scholar
  • 2 Cho SH, Song TJ, Oh D. et al. Endoscopic ultrasound-guided hepaticoduodenostomy versus percutaneous drainage for right intrahepatic duct dilatation in malignant hilar obstruction. J Gastroenterol Hepatol 2024; 39: 552-559
    CrossrefPubMedSearch in Google Scholar

Correspondence

Takeshi Ogura, MD
Endoscopy Center, Osaka Medical and Pharmaceutical University
2-7 Daigakuchou, Takatsukishi
Osaka 569-8686
Japan   

Publication History

Article published online:
02 October 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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  • References

  • 1 Ma KW, So H, Cho DH. et al. Durability and outcome of endoscopic ultrasound-guided hepaticoduodenostomy using a fully covered metal stent for segregated right intrahepatic duct dilatation. J Gastroenterol Hepatol 2020; 35: 1753-1760
    CrossrefPubMedSearch in Google Scholar
  • 2 Cho SH, Song TJ, Oh D. et al. Endoscopic ultrasound-guided hepaticoduodenostomy versus percutaneous drainage for right intrahepatic duct dilatation in malignant hilar obstruction. J Gastroenterol Hepatol 2024; 39: 552-559
    CrossrefPubMedSearch in Google Scholar

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Zoom
Fig. 1 Cholangiography confirms the superficial right hepatic duct puncture.
Zoom
Fig. 2 During endoscopic retrograde cholangiopancreatography catheter insertion, the pushing force deflects to the right side (arrow).
Zoom
Fig. 3 Tract dilation is performed using the drill dilator.
Zoom
Fig. 4 Insertion of the stent delivery system failed due to the pushing force deflecting to the right side (arrow).
Zoom
Fig. 5 Successful stent deployment after employing the double-guidewire technique.