EUS-GUIDED LEFT HEPATICO-DUODENOSTOMY (L-HDS): A NOVEL OPTION FOR EUS-GUIDED BILIARY DRAINAGE (EUS-BD) OF THE LEFT BILE-DUCT WHEN HEPATICOGASTROSTOMY (EUS-HGS) IS NOT FEASIBLE

Introduction: We describe L-HDS as alternative to EUS-HGS in left biliary exclusion when transgastric access is precluded.

Technique: Metastatic gastric adenocarcinoma with hilar block and unilateral right-side SEMS by ERCP presenting with persistent jaundice because of left-side exclusion. Gross linitis precludes transgastric access for EUS-HGS. From the duodenum, the left intrahepatic duct is punctured for EUS-cholangiography and L-HDS performed with FC-SEMS. A second overlapping FC-SEMS is required to overcome foreshortening. Patient experienced 48-hour pain but cleared his jaundice.

Conclusions EUS-BD adapts to individual patient anatomy. L-HDS is more challenging than EUS-HGS but can still provide internal biliary drainage despite linitis.