A novel technique for stent dysfunction after endoscopic ultrasound-guided hepaticogastrostomy with antegrade stenting

Recently, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been developed as a new drainage technique for malignant biliary obstruction; however, a high adverse event rate has been reported [1]. Stent migration is a serious adverse event. The use of long stents in EUS-HGS is therefore recommended to prevent this complication [2]. However, when a long stent is placed in the gastrointestinal lumen, re-intervention at the time of stent dysfunction can be challenging; several re-intervention techniques have been reported [2] [3] [4]. We present a case using a successful simple re-intervention technique for stent dysfunction after EUS-HGS combined with antegrade stenting.

A 67-year-old man with advanced gastric cancer presented with a recurrence of jaundice 6 months after undergoing EUS-HGS combined with antegrade stenting for distal biliary obstruction. An 8 × 100-mm covered metal stent had been deployed during EUS-HGS ([Fig. 1]).

Fig. 1 Gastroscopy showing the endoscopic ultrasound-guided hepaticogastrostomy stent. A 5-cm length of the originally deployed 8 × 100-mm covered metal stent was seen in the gastric lumen.

Because his cholangitis was classified as moderate according to the Tokyo Guideline [5], urgent biliary drainage was attempted. First, a therapeutic duodenoscope was advanced to the EUS-HGS site. Second, a guidewire was advanced through the EUS-HGS and antegrade stents; it was successfully passed via the ampulla into the duodenum ([Fig. 2]). Finally, a 6-Fr endoscopic nasobiliary drainage (ENBD) tube (Flexima; Boston Scientific, Marlborough, Massachusetts, USA) that had been self-adjusted with side holes opened with a hole puncher up to 25 cm from the tip was placed through the HGS and antegrade stents with its tip located in the duodenum ([Fig. 3]). The patient’s cholangitis resolved within a few days. A week after the procedure, the ENBD tube was cut in the gastric lumen using a loop cutter (Olympus, Tokyo, Japan) for internalization ([Fig. 4]; [Video 1]).

Fig. 2 Radiographic image showing a 0.025-inch guidewire that was advanced through both the endoscopic ultrasound-guided hepaticogastrostomy and antegrade stents, and was successfully passed via the ampulla into the duodenum.

Fig. 3 The self-adjusted endoscopic nasobiliary drainage (ENBD) tube: a consisting of commercially available 6-Fr ENBD tube into which side holes were opened with a hole puncher up to 25 cm from the tip; b after placement through the HGS and antegrade stents so that its tip was located in the duodenum.

Fig. 4 The self-adjusted endoscopic nasobiliary drainage tube was cut in the gastric lumen using a loop cutter for internalization, seen on: a fluoroscopic view; b endoscopic view.

Video 1 An endoscopic nasobiliary drainage tube self-adjusted with side holes was placed through the hepaticogastrostomy and antegrade stents. After the patient’s cholangitis had resolved, the drainage tube was cut in the gastric lumen for internalization.

Currently, > 6 months have passed, and the patient is continuing chemotherapy without stent dysfunction. This novel re-intervention technique is simple and could be useful for stent occlusion after EUS-HGS combined with antegrade stenting.

Endoscopy_UCTN_Code_TTT_1AR_2AZ

Competing interests

None

• References

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