Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has a high technical success rate; however, severe adverse events such as biliary peritonitis and stent migration may occur [1]. To reduce these risks, self-expandable metallic stent (SEMS) placement without tract dilation has been reported [2]
[3]. However, the fully-covered and small-diameter design of the SEMS carries a risk of migration [4].
A novel SEMS with a 7-Fr slim delivery system (Niti-S EUS-BD system End Bare Single Flare, 8 mm × 12 cm; Taewoong Medical Co., Ltd., Gimpo, South Korea) features a cross-wire structure that maintains stiffness with a reduced delivery system diameter. It also has an ultra-tapered 0.9-mm tip that minimizes the gap with a 0.025-inch-diameter guidewire, which facilitates smooth insertion of the stent delivery system. Additionally, a partially covered proximal end and flared distal end can prevent stent migration ([Fig. 1]). Herein, we report EUS-HGS without tract dilation using the novel SEMS ([Video 1]).
Fig. 1
a A novel self-expandable metallic stent with a 7-Fr slim delivery system features an ultra-tapered 0.9-mm tip that minimizes the gap with a 0.025-inch-diameter guidewire. b The stent (8 mm × 12 cm) is structured by a cross-wire, partially covered proximal end and a flared distal end.
A novel ultra-tapered slim-delivery metallic stent was successfully placed without tract dilation during endoscopic ultrasound-guided hepaticogastrostomy while minimizing the risk of stent migration.Video 1
An 81-year-old woman with biliary obstruction caused by pancreatic head cancer initially underwent transpapillary SEMS placement. Three months later, EUS-HGS was planned for recurrent biliary obstruction due to complete stent migration ([Fig. 2]). First, intrahepatic bile duct (B2) was punctured with a 19-gauge needle, and a 0.025-inch guidewire (VisiGlide 2; Olympus Medical Systems, Tokyo, Japan) was advanced into the common bile duct after contrast injection. Subsequently, the SEMS with a 7-Fr delivery system was inserted without tract dilation. The ultra-tapered tip passed smoothly into the bile duct, and the SEMS (8 mm × 12 cm) was successfully placed within 10 minutes ([Fig. 3]). The patient showed improvement in jaundice and was discharged without adverse events.
Fig. 2 Computed tomography images show pancreatic head cancer (arrowheads) and dilated intrahepatic bile duct. a Axial plane. b Coronal plane.
Fig. 3 Endoscopic ultrasound-guided hepaticogastrostomy. a Intrahepatic bile duct (B2) is punctured with a 19-gauge needle. b A 0.025-inch guidewire is advanced into the common bile duct. c A 7-Fr delivery system of the stent is inserted without tract dilation. d The self-expandable metallic stent (8 mm × 12 cm) is successfully placed within 10 minutes.
To the best of our knowledge, this is the first case of EUS-HGS without tract dilation using the novel SEMS with an ultra-tapered slim delivery system. This simple technique can offer a safer approach for EUS-HGS.
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