EUS-guided hepaticoduodenostomy combined with antegrade metal stenting using an ultrathin flexible delivery system

EUS-guided hepaticogastrostomy (HGS) combined with antegrade metal stenting (AS) can achieve longer stent patency and may be associated with fewer procedure-related adverse events (AEs) compared to EUS-HGS or EUS-AS alone [1] [2] [3]. However, EUS-guided hepaticoduodenostomy (HDS) with AS remains challenging [4]. Because the angle between the right hepatic bile duct and inserted device is typically extremely acute, antegrade insertion of hard and thick devices, such as a metal stent, is often extremely challenging. Here, we report a successful case of EUS-HDS with AS using a metal stent with 5.4-Fr ultra-thin flexible delivery system and a dedicated plastic stent.

An 84-year-old woman with a history of left lobectomy for liver metastasis of colonic cancer developed jaundice as a result of distal biliary obstruction owing to recurrence ([Fig. 1]). Because endoscopic retrograde cholangiopancreatography (ERCP) had failed, owing to duodenal invasion, EUS-guided drainage was attempted. The right intrahepatic bile duct was punctured using a 19-gauge needle, and a 0.025-inch guidewire was inserted into the bile duct, followed by a tapered catheter. Subsequently, the guidewire traversed the stricture and advanced into the duodenum, and the fistula was dilated using a 4-mm balloon catheter (Kaneka Medix, Osaka, Japan). A novel metal stent with a 5.4-Fr delivery system (8 × 80 mm; Zeo Stent V; Zeon Medical, Tokyo, Japan), which is commercially available in Japan, was subsequently inserted and placed antegrade across the stricture. Finally, a 7-Fr dedicated single-pigtail plastic stent (Gadelius Medical, Tokyo, Japan), originally designed for EUS-HGS [5], was placed from the hepatic duct to the stomach ([Fig. 2] and [Video 1]). The obstructive jaundice improved postoperatively, without any AEs.

Fig. 1 Abdominal computed tomography revealed the right intrahepatic bile duct dilatation, without the left lobe.

Fig. 2 a The angle between the right hepatic bile duct and puncture route was extremely acute. b A 5.4-Fr ultrathin flexible delivery system was inserted into the bile duct. c The metal stent was placed antegrade across the bile duct stricture. d A dedicated single-pigtail stent was placed from the hepatic duct to the stomach.

Video 1 EUS-guided hepaticoduodenostomy with antegrade metal stenting using a metal stent with 5.4-Fr ultra-thin flexible delivery system and a dedicated plastic stent.

The ultrathin flexible metal stent delivery system may facilitate AS through EUS-HDS. This procedure may be a useful option for treating malignant biliary obstruction in patients with failed ERCP who require an approach via the right intrahepatic bile duct.

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Mukai S, Itoi T. EUS-guided antegrade procedures. Endosc Ultrasound 2019; 8: S7-S13
• 2 Ogura T, Kitano M, Takenaka M. et al. Multicenter prospective evaluation study of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting (with video). Dig Endosc 2018; 30: 252-259
• 3 Yamamoto K, Itoi T, Tsuchiya T. et al. EUS-guided antegrade metal stenting with hepaticoenterostomy using a dedicated plastic stent with a review of the literature (with video). Endosc Ultrasound 2018; 7: 404-412
• 4 Park SJ, Choi JH, Park DH. et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc 2013; 78: 374-380
• 5 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

Publication History

Article published online:
19 February 2021