Endoscopic ultrasound-guided hepaticoduodenostomy with anterograde stenting for recurrent hepatic hilar obstruction

We present the case of a 52-year-old woman who underwent endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS) with anterograde stenting. She had undergone side-by-side stent drainage (the left hepatic and anterior bile ducts) for Bismuth type II hilar bile duct obstruction (HBO) caused by intrahepatic cholangiocarcinoma. She was diagnosed with cholangitis in the posterior bile duct (B6) due to stent occlusion 2 months later. Endoscopic retrograde cholangiopancreatography was performed, but the catheter could not be inserted into B6 ([Fig. 1]). Although balloon dilation of the stent mesh was performed, even the thinnest (5.7 Fr) uncovered self-expandable metal stent (UCSEMS) could not be inserted. Therefore, we performed anterograde stenting via EUS-HDS.

Fig. 1 Images showing: a, b the appearance of the uncovered self-expandable metal stents that had been previously deployed into the hilar biliary obstruction using the side-by-side method; c dilatation of the B6 duct; d the guidewire inserted into the B6 duct during endoscopic retrograde cholangiopancreatography; however, the catheter and stent could not then be inserted.

The EUS scope was inserted into the descending duodenum. The B6 duct was identified and punctured with a 19G needle. A 0.025-inch guidewire was inserted from B6 into the common bile duct (CBD) through the mesh of the previous UCSEMS. The fistula site was dilated with a 4-mm balloon. A UCSEMS (8 mm × 6 cm; ZEOSTENT; Zeon Medical, Tokyo, Japan) was deployed from B6 to the CBD using anterograde stenting. Additionally, a fully covered SEMS (8 mm × 8 cm; X-SUIT NIR; Olympus, Tokyo, Japan) was deployed at the fistula site. Finally, cholangiography was performed and confirmed the passage of contrast from B6 via the CBD to the duodenum ([Fig. 2]; [Video 1]).

Fig. 2 Endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS) with anterograde stenting showing: a the posterior branch (B6) clearly visualized by EUS from the descending duodenum; b puncture of the B6 duct with a 19G needle being confirmed by cholangiogram; c, d the fistula site being dilated, with a guidewire passed between the mesh of an uncovered self-expandable metal stent (UCSEMS) in the B8 duct, before a UCSEMS is deployed from the B6 branch to the common bile duct using the stent-in-stent method; e cholangiography to confirm the flow of contrast from B6 via the common bile duct to the duodenum, passing through the fully covered SEMS deployed at the fistula site.

Video 1 Video showing a novel reintervention method for hilar biliary obstruction using endoscopic ultrasound-guided hepaticoduodenostomy with anterograde stenting.

Post-procedure computed tomography revealed that the intrahepatic bile duct dilatation had disappeared ([Fig. 3]). There were no procedure-related complications. Clinically, with the cholangitis improved, the patient was able to resume her chemotherapy.

Fig. 3 Computed tomography (CT) images after endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS) showing: a the coronal view; b the sagittal view; c a 3 D construction using a work station (Ziostation2; Ziosoft Inc., Tokyo, Japan).

Reintervention after SEMS deployment for HBO is difficult because it is performed after multi-stenting with a UCSEMS. EUS-HDS [1] [2] [3] is an alternative drainage route for HBO; however, there were no reports on EUS-HDS with anterograde stenting. This is the first report demonstrating the usefulness of EUS-HDS with anterograde stenting as a rescue drainage procedure for HBO cases wherein reintervention is difficult.

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Competing interests

The authors declare that they have no conflict of interest.

Acknowledgment

We thank Mr. Yuya Kanai for the help in creating the figures.

• References

• 1 Hijioka S, Sakamoto Y, Ohba A. et al. Novel simultaneous endoscopic ultrasound-guided hepaticoduodenostomy and hepaticogastrostomy for recurrent hepatic hilar obstruction. Endoscopy 2018; 50: e320-e322
• 2 Ma KW, So H, Cho DH. et al. Durability and outcome of endoscopic ultrasound-guided hepaticoduodenostomy using a fully covered metal stent for segregated right intrahepatic duct dilatation. J Gastroenterol Hepatol 2020; 35: 1753-1760
• 3 Hori Y, Hayashi K, Naitoh I. et al. Combined transpapillary drainage and endoscopic ultrasound-guided hepaticoduodenostomy after failed manipulation under cholangioscopy guidance. Endoscopy 2020;

Publication History

Article published online:
27 August 2021