The usefulness of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for biliary obstruction has been widely reported in cases where a transpapillary approach is unsuitable or impossible [1]
[2]. Covered self-expandable metal stents (CSEMSs) are often used for EUS-HGS, and the presence of the cover provides peace of mind that bile leakage will not occur, even if the CSEMS passes through the abdominal cavity [3]; however, we report here a case in which, despite successful EUS-HGS using a CSEMS, biliary peritonitis occurred immediately afterward owing to a broken “cover” ([Video 1]).
Qualität:
A case in which, despite successful endoscopic ultrasound-guided hepaticogastrostomy using a covered self-expandable metal stent for biliary obstruction due to unresectable distal biliary cancer, biliary peritonitis occurred immediately afterward owing to a broken “cover.”Video 1
A 65-year-old man diagnosed with unresectable distal biliary cancer developed obstructive
jaundice and underwent transpapillary CSEMS placement ([Fig. 1]); however, he developed cholangitis due to biliary hemorrhage and, at the time of
reintervention, the tumor had invaded the duodenum, making the transpapillary approach
impossible. Therefore, we performed biliary drainage by EUS-HGS. The intrahepatic bile duct B3
was punctured with a 19-gauge needle, and a 0.025-inch guidewire was inserted ([Fig. 2]
a). After the fistula had been dilated with a drill dilator
([Fig. 2]
b), a CSEMS (8 × 120 mm; Hanarostent Biliary Partial Cover
Benefit; Boston Scientific, Massachusetts, USA) was quickly placed using the intrascope channel
release technique ([Fig. 2]
c, d).
Fig. 1 Computed tomography images showing obstructive jaundice due to distal biliary cancer.
Fig. 2 Images during biliary drainage using endoscopic ultrasound-guided hepaticogastrostomy
showing: a a 0.025-inch guidewire inserted into the common bile
duct after puncture of B3; b fistula dilation with a drill dilator;
c, d a covered self-expandable metal stent, with a 5.9-cm thin
delivery system and a 15-mm uncovered portion at the hepatic tip, placed from the B3 bile
duct to the stomach.
All of the steps of the procedure were completed without any problems; however, the patient
complained of fever and abdominal pain, and a computed tomography scan on the following day
revealed ascites and free air in the abdominal cavity ([Fig. 3]
a). The bilirubin level in the ascites was high, so it was
thought to be biliary peritonitis. Fistulography revealed contrast leakage from the CSEMS
passing through the abdominal cavity ([Fig. 3]
b, c). Additional stenting was performed to cover the leak
([Fig. 3]
d), and the biliary peritonitis improved with peritoneal
drainage and antibiotic treatment.
Fig. 3 Images after the patient developed biliary peritonitis showing: a on computed tomography the following day, ascites and free air in the abdominal
cavity, with the covered self-expandable metal stent (CSEMS) having passed through the
abdominal cavity between the stomach and liver (arrow), although its position had not
changed from the day of the ultrasound-guided hepaticogastrostomy (EUS-HGS); b, c on fistulography performed 2 days after the EUS-HGS, contrast
leakage from the CSEMS passing through the abdominal cavity (arrowhead); d an additional stent placed to cover the leak.
This case taught us that we should not be overconfident about the “cover” of a CSEMS in EUS-HGS.
Endoscopy_UCTN_Code_CPL_1AL_2AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
