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DOI: 10.1055/a-0889-7329
Transverse stent placement for hilar malignant biliary obstruction through an endoscopic ultrasound-guided hepaticogastrostomy route
Publikationsverlauf
Publikationsdatum:
09. Mai 2019 (online)
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A 70-year-old woman who had undergone endoscopic placement of multiple stents for hilar biliary obstruction due to gallbladder cancer was admitted with cholangitis. In her previous hospitalization, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) had been performed for the bile duct at segment III (B3) using a partially covered self-expandable metal stent (SEMS; modified Giobor, 10 × 80 mm; Taewoong Medical Inc., Gimpo, Korea [1]). To manage subsequent episodes of cholangitis, two uncovered SEMSs were placed via the transpapillary route for B7 and B8 in a partial stent-in-stent fashion ([Fig. 1]). On this admission, endoscopic drainage was scheduled to manage segmental cholangitis in B8.
![](https://www.thieme-connect.de/media/endoscopy/201909/thumbnails/10-1055-a-0889-7329-i1031ev1.jpg)
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In the first session, transpapillary biliary drainage of B8 failed as a cannula could not be passed through the mesh wall of the indwelling SEMS ([Fig. 2 a]). Therefore, we attempted to access B8 though the EUS-HGS stent. Using a side-viewing duodenoscope, we passed a guidewire into the ventral branch of B8 and dilated the mesh of the SEMS using a balloon catheter ([Fig. 2 b]). We then placed a nasobiliary catheter to manage the cholangitis. In the following session, we trimmed the gastric end of the EUS-HGS stent using argon plasma coagulation (ESG-100; Olympus, Tokyo, Japan) to facilitate insertion of the stent [2] and deployed an uncovered SEMS (Niti-S, 10 × 80 mm; Taewoong Medical Inc.) ([Fig. 2 c]; [Video 1]). There were no procedure-related adverse events.
![](https://www.thieme-connect.de/media/endoscopy/201909/thumbnails/10-1055-a-0889-7329-i1031ev2.jpg)
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Video 1 Placement of a metal stent bridging a hilar malignant biliary stricture through an indwelling hepaticogastrostomy stent.
Qualität:
Endoscopists occasionally face technical difficulties in managing occlusion of SEMSs placed for hilar biliary obstruction. The transpapillary approach is often used for re-intervention for the right-sided biliary system and, recently, the feasibility of EUS-guided hepaticoduodenostomy has been reported [3] [4]; however, both procedures are technically demanding. Furthermore, EUS-guided access to B8 is often anatomically impossible. Access to the right intrahepatic bile duct via the EUS-HGS route can offer an alternative strategy in this setting [5].
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References
- 1 Nakai Y, Isayama H, Yamamoto N. et al. Safety and effectiveness of a long, partially covered metal stent for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction. Endoscopy 2016; 48: 1125-1128
- 2 Hamada T, Nakai Y, Isayama H. et al. Trimming a covered metal stent during hepaticogastrostomy by using argon plasma coagulation. Gastrointest Endosc 2013; 78: 817
- 3 Ogura T, Sano T, Onda S. et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy 2015; 47: 72-75
- 4 Park SJ, Choi JH, Park DH. et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc 2013; 78: 374-380
- 5 Prachayakul V, Aswakul P. Endoscopic ultrasound-guided biliary drainage: Bilateral systems drainage via left duct approach. World J Gastroenterol 2015; 21: 10045-10048