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DOI: 10.1055/s-0043-101225
Endoscopic ultrasonography-guided antegrade stenting combined with hepaticogastrostomy/hepaticojejunostomy using ultraslim instruments
Publication History
Publication Date:
13 February 2017 (online)


Techniques for endoscopic ultrasonography (EUS)-guided biliary drainage (EUS-BD) have been developed, and EUS-guided antegrade stenting (EUS-AGS) and EUS-guided hepaticogastrostomy (EUS-HGS)/hepaticojejunostomy (HJS) are suitable for gastric outlet obstruction (GOO) or surgically altered anatomy. EUS-AGS alone carries the potential risk of causing bile leakage from a fistula; however, EUS-AGS in combination with EUS-HGS or EUS-HJS appears safer, as it can reduce the risk of a bile leak [1] [2].
We present two patients who underwent EUS-HGS or EUS-HJS combined with EUS-AGS using ultraslim instruments. Patient #1 was a 62-year-old woman who had undergone a previous total gastrectomy for gastric cancer and later developed obstructive jaundice. First, a B3 branch was punctured using a 19G needle via a transjejunal approach, and a 0.025-inch guidewire (VisiGlide 2; Olympus, Tokyo, Japan) ([Fig. 1]) was placed. Next, a tapered endoscopic retrograde cholangiopancreatography (ERCP) catheter (01 20 21 1; MTW Endoskopie, Düsseldorf, Germany) ([Fig. 2]) was used to dilate the fistula, following successful passage of the guidewire through the stricture. EUS-AGS was then performed using a novel ultraslim uncovered self-expandable metal stent (SEMS; BileRush Selective; 5.7 Fr, 10-mm diameter; Piolax Medical Devices, Kanagawa, Japan) ([Fig. 2]). Finally, a novel 7-Fr plastic stent (TYPE-IT stent; Gadelius Medical Co. Ltd., Tokyo, Japan) [3] ([Fig. 3]) was placed to create an EUS-HJS ([Fig. 4]; [Video 1]).












Quality:
Patient #2 was a 68-year-old man with GOO caused by gastric cancer who developed obstructive jaundice. EUS-AGS and EUS-HGS were performed as described above ([Fig. 5]; [Video 2]). There were no complications in either case.



Quality:
A covered SEMS (CSEMS) is commonly used to prevent bile leaks in EUS-HGS/HJS. A long partially covered SEMS (PCSEMS; ≥ 10 mm) can be used to prevent stent migration [4]. However, the thicker delivery system (8.5 Fr) with this long PCSEMS and the cost of two metal stents are of concern. In particular, minimum fistula dilation should be performed during EUS-BD. Therefore, EUS-AGS and EUS-HGS/HJS using various ultraslim instruments (7 Fr or less) in combination can facilitate the procedure and minimize the potential for bile leakage.
Endoscopy_UCTN_Code_TTT_1AS_2AD