Re-intervention for recurrent biliary obstruction after endoscopic ultrasound hepaticogastrostomy with partially covered self-expandable metal stent

The use of the endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) method for malignant biliary stricture has increased. A partially covered self-expandable metal stent (PCSEMS) is often selected for the procedure, and re-intervention is challenging because of the long length of stent protrusion inside the stomach. Several re-intervention methods, including trimming and stent penetration using electrical devices, have been reported [1] [2] [3] [4]; however, the complexity and time-consuming nature of these procedures pose limitations. Here, we report the simplest of novel re-intervention methods for PCSEMS dysfunction after an EUS-HGS.

A 65-year-old woman with unresectable pancreatic cancer and duodenal obstruction underwent EUS-HGS using a PCSEMS (Niti-S biliary S-type; 8-mm × 10-cm covered stent with a 1-cm uncovered portion; Taewoong Medical, Seoul, South Korea). After 8 months had passed, recurrent biliary obstruction occurred due to bile duct hyperplasia at the stent edge ([Fig. 1]). Stent removal with a grasping forceps was not possible because it was firmly anchored by the overgrown tissue. Inserting a guidewire and a catheter parallel to the stent to access the bile duct was also not feasible.

Fig. 1 Recurrent biliary obstruction after endoscopic ultrasound-guided hepaticogastrostomy shown on: a computed tomography image; b endoscopic view.

We therefore penetrated the stent mesh close to the stomach wall with a guidewire (Visiglide2; Olympus, Tokyo, Japan) and a catheter (Tandem XL ERCP Cannula; Boston Scientific Corporation, Marlborough, Massachusetts, USA). These devices were advanced into the stent ([Fig. 2]), and bypassed the stricture allowing access to the bile duct. The biliary stricture and the stent mesh, at the entry point of the wire and catheter, were dilated with a balloon catheter (REN; 8-mm wide; Kaneka Medix Corporation, Tokyo). A fully covered SEMS (Niti-S biliary S-type; 6-mm × 8-cm long covered stent; Taewoong Medical) was threaded through the dilated tract and successfully deployed ([Fig. 3], [Video 1]). This procedure was completed without any adverse events.

Fig. 2 Endoscopic view showing a 0.025-inch guidewire and a catheter penetrating through the mesh of the previously placed hepaticogastrostomy stent near the stomach wall.

Fig. 3 A fully covered self-expandable metal stent (arrow) is positioned through the previously placed stent, as shown on: a endoscopic view; b computed tomography (CT) image; c reconstructed CT image.

Video 1 The video shows a novel re-intervention method for recurrent biliary obstruction after endoscopic ultrasound-guided hepaticogastrostomy with a partially covered self-expandable metal stent.

This novel re-intervention method involving penetration of the stent mesh near the stomach wall is simple, safe, and efficient.

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• References

• 1 Yane K, Katanuma A, Maguchi H. et al. Successful re-intervention with metal stent trimming using argon plasma coagulation after endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2014; 46: E391-E392
• 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 Minaga K, Takenaka M, Okamoto A. et al. Reintervention for stent occlusion after endoscopic ultrasound-guided hepaticogastrostomy with novel use of a precut needle-knife. Endoscopy 2018; 50: E153-E154
• 4 Ogura T, Masuda D, Takeuchi T. et al. Simplified reintervention method of EUS-guided hepaticogastrostomy stent obstruction. Gastrointest Endosc 2016; 83: 831