Re-intervention with endoscopic ultrasound-guided hepaticogastrostomy for unresectable hilar biliary drainage using a multipath occlusion balloon

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) and antegrade stenting (EUS-AS) have been developed as alternative biliary drainage methods; however, treating unresectable malignant hilar biliary strictures remains challenging [1] [2] [3]. We successfully performed re-intervention for malignant hilar biliary drainage after EUS-HGS using a multipath occlusion balloon.

A 46-year-old woman who was on medication for a postoperative recurrence of gastric cancer presented with jaundice. She had previously undergone double-balloon enteroscope (DBE)-assisted biliary drainage with a self-expandable metal stent (SEMS) for malignant biliary stricture of the lower bile duct.

Contrast-enhanced computed tomography (CT) showed strictures of the hilar bile duct and duodenum ([Fig. 1]) associated with dissemination of the gastric cancer. EUS-HGS was performed ([Fig. 2]), and a 7-Fr plastic stent (TYPE-IT; Gadelius Medical, Tokyo, Japan) was placed into the B3 bile duct [4]. However, the patient’s jaundice was not improved, and re-intervention was required. A 0.025-inch guidewire was placed into the duodenum beyond the papilla, and the plastic stent was removed. A second 0.025-inch guidewire was placed into the B5 bile duct using a multipath occlusion balloon (Bouncer; Cook Medical, Tokyo, Japan) ([Fig. 3]). This balloon has a multilumen located at either end of the balloon, which enables guidewires to be passed easily into crooked bile ducts ([Fig. 3] and [Fig. 4 a]; [Video 1]). A Zilver 635 biliary SEMS (Cook Medical, Tokyo, Japan) was introduced over the first guidewire and placed into the B5 bile duct, bridging the right and left hepatic ducts ([Fig. 4 b]). Finally, a modified Niti-S GIOBOR biliary stent (Century Medical, Tokyo, Japan) was placed into the B3 bile duct ([Fig. 4 c]). The jaundice subsequently improved, and no adverse events occurred.

Fig. 1 Contrast-enhanced computed tomography image showing strictures of the hilar bile duct (red arrow) and duodenum (blue arrow) associated with the dissemination of gastric cancer.

Fig. 2 Endoscopic ultrasound-guided hepaticogastrostomy was performed and a 7-Fr plastic stent was placed into the B3 bile duct.

Fig. 3 The multipath occlusion balloon (Bouncer; Cook Medical, Tokyo, Japan) has a multilumen located at either end of the balloon, which enables guidewires to be passed easily into crooked bile ducts.

Fig. 4 Radiographic images showing: a a guidewire placed into the B5 bile duct using a multipath occlusion balloon (red arrow); b a self-expandable metal stent (SEMS) introduced over the first guidewire and placed into the B5 bile duct, bridging the right and left hepatic ducts; c a second SEMS placed into the B3 bile duct bridging the hepatogastric stoma.

Video 1 Re-intervention with endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). Drainage of the right hepatic duct was challenging, but we achieved technical success using a multipath occlusion balloon.

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• References

• 1 Paik WH, Lee NK, Nakai Y. et al. Conversion of external percutaneous transhepatic biliary drainage to endoscopic ultrasound-guided hepaticogastrostomy after failed standard internal stenting for malignant biliary obstruction. Endoscopy 2017; 49: 544-548
• 2 Ogura T, Kitano M, Takenaka M. et al. A multicenter prospective evaluation study of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting (with video). Dig Endosc DOI: 10.1111/den.12976.
• 3 Koshitani T, Nakagawa S, Itoh Y. EUS-guided antegrade stent placement for unresectable malignant hilar biliary strictures by use of a stent-in-stent method. Gastrointest Endosc 2018; 87: 309-310
• 4 Umeda J, Itoi T, Tsuchiya T. et al. A newly designed plastic stent for EUS-guided hepaticogastrostomy: a prospective preliminary feasibility study (with videos). Gastrointest Endosc 2015; 82: 390-396