Donʼt be overconfident about the “cover” of a covered self-expandable metal stent in endoscopic ultrasound-guided hepaticogastrostomy

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]).

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.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Binda C, Dajti E, Giuffrida P. et al. Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy: a meta-regression analysis. Endoscopy 2023; 56: 694-705
• 2 Khoury T, Sbeit W, Fumex F. et al. Endoscopic ultrasound- versus ERCP-guided primary drainage of inoperable distal malignant biliary obstruction: systematic review and meta-analysis of randomized controlled trials. Endoscopy 2024; 56: 955-963
• 3 Ogura T, Higuchi K. Endoscopic ultrasound-guided hepaticogastrostomy: technical review and tips to prevent adverse events. Gut Liver 2021; 15: 196-205

Publication History

Article published online:
16 January 2025