Surgical hepaticogastrostomy as a method for resolving stent migration in endoscopic ultrasound-guided hepaticogastrostomy

A 54-year-old woman presented with a 1-month history of jaundice. Abdominal CT showed a perihilar hypodense mass measuring 21 × 16 mm in diameter with dilated bilateral intrahepatic bile duct (IHD). Hilar cholangiocarcinoma was diagnosed and palliative biliary drainage was scheduled. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) was performed with the patient under general anesthesia. A linear echoendoscope along with a 19-gauge EUS-FNA needle, a 0.025-inch guidewire, a 6-French cystotome, and serial bougie dilators up to 8.5 French were used. A 120-mm partially covered stent with distal flared end (Giobore biliary stent; Taewoong Medical Co., Ilsan, Korea) was used to bridge the left IHD and stomach using the extra-scope channel deployment technique. The proximal end was successfully placed into the left IHD, but the distal end unfortunately displaced into the peritoneal cavity. We immediately converted EUS-HGS to exploratory laparotomy ([Video 1]). The displaced distal end of the HGS stent and a hole on the serosal side of the stomach were identified ([Fig. 1]). The distal end of the HGS stent was placed back into the stomach ([Fig. 2]) and sutured to the stomach wall. Surgical hepaticogastrostomy was then successfully performed with the HGS stent. No postoperative adverse events occurred. The patient resumed a regular diet on day 4 and was discharged on day 7. She has been well without a need for biliary reintervention during 15 months of follow-up.

Video 1 Exploratory laparotomy with surgical resolution of migrated stent during endoscopic ultrasound-guided hepatogastrostomy.

Fig. 1 During exploratory laparotomy following early stent migration during endoscopic ultrasound-guided hepatogastrostomy, the hepatogastrostomy stent (arrowhead) and the hole (arrow) in the stomach (star) were identified.

Fig. 2 During exploratory laparotomy, the hepatogastrostomy stent (arrowhead) was placed back into the hole (arrow) in the stomach (star).

Stent migration, either as an early event during stent deployment [1] or as late migration due to stent shortening, occurs in about 2 % to 3 % of cases [2]. Migration can be a fatal complication of EUS-HGS. Immediate stent migration can be treated with various techniques such as tandem stent placement [3], surgical removal [4], or endoscopic retrieval [5]. With the present case, we report surgical hepaticogastrostomy as another technique to resolve early HGS stent migration.

Endoscopy_UCTN_Code_CPL_1AL_2AD

• References

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