Endoscopic ultrasonography-guided B3 branch drainage/anastomosis as hepaticoduodenostomy in atrophic left hepatic lobe case

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is widely performed as a salvage procedure when endoscopic retrograde cholangiopancreatography (ERCP) is difficult or has failed [1] [2]. EUS-HGS is the most common type of EUS-guided biliary drainage or anastomosis (EUS-BD/A) for the left intrahepatic bile duct (IHBD), which is punctured from the stomach [3]. In contrast, EUS-guided hepaticoduodenostomy (EUS-HDS) is usually performed by approaching the right IHBD from the duodenum [4]. However, we report a case of EUS-HDS approaching the left IHBD in a patient with an atrophic left hepatic lobe.

A 76-year-old man with distal biliary obstruction due to duodenal cancer was hospitalized ([Fig. 1]). The patient was unfit for surgery because of severe obstructive pulmonary dysfunction, and a 7-Fr straight biliary plastic stent (PS) was placed transpapillary. When the PS became occluded, reapproaching the papilla was unsuccessful because of duodenal obstruction. EUS-HGS was attempted, but the liver could not be visualized from the stomach due to atrophy of the left hepatic lobe. A slightly dilated B3 branch (approximately 2 mm) was visualized from the first portion of the duodenum using a convex-type echoendoscope (EG-740UT, Fujifilm Corp.,Tokyo, Japan) [5], and puncture was performed with a 19-gauge needle (EZ Shot 3 Plus, Olympus, Tokyo, Japan). After successful puncture and cholangiogram, a 0.025-inch guidewire (VisiGlide2, Olympus, Tokyo, Japan) was inserted. The tract was dilated using a drill (Tornus ES; Asahi Intec, Aichi, Japan) and a 4-mm balloon dilator (REN; Kaneka, Osaka, Japan). Finally, a partially covered self-expandable metallic stent with an antimigration system (8 mm×12 cm Spring Stopper; Taewoong Medical, Seoul, Korea) was deployed ([Fig. 2]; [Video 1]). Post‐procedural computed tomography confirmed appropriate stent placement and no adverse events were observed.

Fig. 1 a Computed tomography showing wall thickening of the duodenum and dilation of the common bile duct and intrahepatic bile ducts. b An endoscopic image showing circumferential wall thickening of the descending duodenum. The tumor involves major papilla.

Fig. 2 a A fluoroscopic image showing puncture and opacification of the B3 using a 19-gauge needle through the echoendoscope. b A partially covered self‐expandable metallic stent (SEMS) with an antimigration system was deployed between the B3 and the duodenum. c An endoscopic view showing the SEMS in the duodenum with an adequate intraduodenal portion. d A sagittal computed tomography image confirming the appropriate positioning of the metallic stent without bile leakage.

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Endoscopic ultrasound-guided drainage/anastomosis of the B3 as hepaticoduodenostomy.Video 1

In standard practice, EUS-HDS targets the right IHBD from the first portion of the duodenum. However, in cases with an atrophic left hepatic lobe, EUS-HDS targeting the left IHBD may also represent a feasible option for EUS-BD/A.

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Contributorsʼ Statement

Kohei Kurihara: Investigation, Resources. Hiroyuki Isayama: Project administration, Writing – review & editing. Ayane Matsuzaki: Data curation, Resources. Ryunosuke Hakuta: Data curation, Writing – original draft. Naminatsu Takahara: Project administration, Writing – review & editing. Yukiko Ito: Project administration, Writing – review & editing. Hideo Yoshida: Project administration, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Isayama H, Nakai Y, Itoi T. et al. Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018. J Hepatobiliary Pancreat Sci 2019; 26: 249-269
• 2 Isayama H, Nakai Y, Matsuda K. et al. Proposal of classification and terminology of interventional endoscopic ultrasonography/endosonography. Dig Endosc 2025; 37: 5-17
• 3 Paik WH, Lee TH, Park DH. et al. EUS-Guided Biliary Drainage Versus ERCP for the Primary Palliation of Malignant Biliary Obstruction: A Multicenter Randomized Clinical Trial. Am J Gastroenterol 2018; 113: 987-997
• 4 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
• 5 Fujisawa T, Ishii S, Nakai Y. et al. Dedicated Echoendoscope for Interventional Endoscopic Ultrasound: Comparison with a Conventional Echoendoscope. J Clin Med 2024; 13: 2840

Publication History

Article published online:
28 January 2026