Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a widely used procedure;
however, it is challenging in patients with a nondilated bile duct [1]. Although, the double-wall puncture (Seldinger’s method) can be helpful in such
cases ([Fig. 1]), specific methods to confirm successful puncture have not been established [2]
[3]. Aspiration of a large amount of bile can lead to bile duct collapse, making guidewire
insertion difficult. On the other hand, if contrast agent is injected without recognizing
that the puncture has failed, extravasation may occur outside of the bile duct. Herein,
we demonstrate the use of two novel methods to confirm successful EUS-HGS puncture
([Video 1]).
Fig. 1 Schema of double-wall puncture showing: a a nondilated bile duct; b double-wall puncture (puncture of both anterior and posterior wall); c pull back of the needle into the bile duct lumen; d subsequent contrast injection and guidewire insertion.
Novel methods, the moving bubble sign and Doppler sign, are demonstrated, which can
be helpful to confirm successful puncture in endoscopic ultrasound-guided hepaticogastrostomy.Video
1
Moving bubble sign: Before puncture, an extension tube and a 10-mL syringe were attached to the end of
a 19-gauge needle. The tube and needle were filled with contrast agent, with a small
number of air bubbles within it ([Fig. 2]). After the double-wall puncture, the physician slowly pulled back the needle tip
under ultrasound guidance. When the needle tip appeared to return inside the bile
duct, the assistant applied slight negative pressure to the syringe. A successful
puncture was confirmed when the air bubbles moved smoothly. If the puncture was unsuccessful,
the air bubbles remained stationary. Once this sign had been seen, cholangiography
was performed successfully.
Fig. 2 Photograph showing the extension tube filled with contrast agent with a few air bubbles
within it that is connected to the end of needle.
Doppler sign: During puncture in EUS-HGS, Doppler imaging was used to avoid accidental puncture
of the major vessels. When the assistant created negative pressure after successful
puncture, the Doppler signal aligned with the needle ([Fig. 3]). Once this sign had been recognized, cholangiography was successfully performed.
The Doppler signal was beneficial to confirm successful puncture when the needle tip
visibility was poor.
Fig. 3 Images of endoscopic ultrasound-guided hepaticogastrostomy being performed in a patient
with a nondilated bile duct showing: a the nondilated bile duct being punctured with a 19-gauge needle; b double-wall puncture being performed; c the Doppler signal aligning with the needle when an assistant creates negative pressure;
d cholangiography being successfully performed.
To the best of our knowledge, this is the first report to describe possible methods
for confirmation of successful puncture in EUS-HGS. These methods facilitate cholangiography
and guidewire manipulation.
Endoscopy_UCTN_Code_TTT_1AS_2AH
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.
