SINGLE-SCOPE TRANSGASTRIC ANTEGRADE CHOLANGIOSCOPY (STAC) AND INTRADUCTAL POLYPECTOMY VIA EUS-GUIDED HEPATICOGASTROSTOMY (HGS) WITH A LUMEN-APPOSING-METAL STENT (LAMS)

EUS-FNA failed to diagnose polypoid hilar cholangiocarcinoma and ERCP failed to drain the up- stream duct. EUS-guided hepaticogastrostomy (HGS) was performed with a lumen-apposing metal stent (LAMS). Biliary drainage and access for single-scope transgastric antegrade cholangioscopy (STAC) was possible. Cholangiocarcinoma was diagnosed in the resected specimen of STAC-guided intraductal polypectomy.

DESCRIPTION. HGS was performed after failed ERCP and EUS-guided FNA. EUS-guided 19G needle access into a segment II radicle was achieved. Marked intrahepatic dilation and proximity to the GI wall allowed transgastric deployment of a dedicated, 8 × 8 mm fully-covered LAMS for HGS. The rationale for LAMS-HGS was to offer large-diameter drainage preventing blockage of peripheral branches. HGS with a plastic stent in a dilated biliary ducts have a high risk of bile leakage. Two 7F pig-tail stents were placed through the LAMS in opposite directions to prevent dysfunction. EUS-FNA and brush cytology of a polypoid mass in the proximal CBD was performed with eventually inconclusive results. The patient cleared his jaundice. A second attempt at tissue diagnosis was made two weeks later. A transnasal upper endoscope 5-mm in diameter was passed through the LAMS into the proximal CBD, where a polypoid mass was seen. The LAMS was removed and the scope was reintroduced through the naked mature HGS fistula. A modified Intraductal polypectomy was performed with 5F-polypectomy snare and the specimen was retrieved. Tissue diagnosis of cholangiocarcinoma was confirmed. The LAMS was put back in place at the HGS. Two argon fulguration sessions by STAC through HGS were performed. Patient remains asymptomatic.

Conclusions:

Favorable Anatomical and technical factors made EUS-guided HGS with LAMS the best option in this case. Specimen of STAC-guided Intraductal polypectomy afforded tissue diagnosis of cholangiocarcinoma after prior negative EUS-FNA. Coaxial Pigtail minimize the risk of migration. Several successful tumor ablation sessions using STAC by HGS were performed.