Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) can be indicated for
failed endoscopic retrograde cholangiopancreatography (ERCP). Recently, various transendoscopic
ultrasonography/endosonography-created route procedures have been developed, such
as antegrade bile duct stone removal and stricture management [1]. These procedures may be mainly indicated for benign biliary disease. Compared with
malignant biliary disease, EUS-HGS might be challenging in cases of benign biliary
disease because the intrahepatic bile duct is not very dilated. Indeed, compared with
a meta-analysis of EUS-HGS for malignant biliary disease [2], the technical success rate might be lower for benign biliary disease [3]. A 22 G needle may improve the technical success of bile duct puncturing. However,
because a 0.018-inch guidewire, which has little stiffness, should be used, device
insertion into the biliary tract may be challenging. To overcome this, a novel dilation
device (Meissa; Japan Lifeline, Tokyo, Japan) has been developed ([Fig. 1]). This device has a 2.3-Fr tip and a maximum diameter of 7.4 Fr. In addition, a
2-cm side hole is provided from the tip. Contrast medium injection, aspiration of
bile juice, and 0.025-inch guidewire insertion can be performed. Therefore, if this
device is used, the double-guidewire technique can be performed without additional
device exchange with a 0.018-inch guidewire. A challenging case of EUS-HGS due to
a non-dilated bile duct is described.
Fig. 1 A novel double lumen dilation device.
An 80-year-old man was referred to our hospital due to acute cholangitis caused by
a common bile duct stone. He underwent distal gastrectomy with a Roux-en-Y anastomosis.
Stone removal was then performed through an enteroscopic approach in another hospital
but failed. Therefore, EUS-HGS was attempted. Since the diameter of the intrahepatic
bile duct was only 1 mm ([Fig. 2], arrow), a 22 G needle was selected as the puncture needle. The intrahepatic bile
duct was successfully punctured and contrast medium was also injected. Then, a 0.018-inch
guidewire was inserted ([Fig. 3]). Next, insertion of the novel dilation device was attempted, and it was easily
inserted into the biliary tract. Subsequently, bile juice was aspirated and contrast
medium was injected. On cholangiography, a common bile duct stone was observed. A
0.025-inch guidewire was inserted through the side hole of the novel dilator ([Fig. 4]). After tract dilation, an 8.5-Fr stent delivery system was easily inserted and
successfully deployed from the intrahepatic bile duct to the stomach ([Fig. 5]) without any adverse events ([Video 1]). After the cholangitis resolved, antegrade removal of the stone was successfully
performed.
Fig. 2 The diameter of the intrahepatic bile duct is only 1 mm (arrow).
Fig. 3 After successful bile duct puncture using 22 G needle, a 0.018-inch guidewire is inserted.
Fig. 4 A 0.025-inch guidewire is inserted through the side hole of the novel dilator.
Fig. 5 After tract dilation, an 8.5-Fr stent delivery system is easily inserted and successfully
deployed from the intrahepatic bile duct to the stomach.
Successful endoscopic ultrasound-guided hepaticogastrostomy using a novel double-lumen
tapered dilator combined with a 22 G needle.Video 1
In conclusion, this dilation device may be useful for EUS-HGS using a 22 G needle
combined with a 0.018-inch guidewire. Additional cases are needed to further evaluate
this device.
Endoscopy_UCTN_Code_TTT_1AS_2AH
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