Introduction
Reports have described the increasing use of endoscopic ultrasound-guided hepaticogastrostomy
(EUS-HG) to treat malignant biliary obstruction in patients with endoscopic retrograde
cholangiopancreatography (ERCP) failure. However, a previous review article noted
that despite its high success rate, EUS-HG is associated with a relatively high rate
of adverse events [1], which is attributable to the lack of standardized protocols and specialized equipment.
Previously at our institution, EUS-HG was performed on three patients using a biliary
dilation catheter for hepaticogastric fistula dilation and a 7-cm, straight plastic
stent or 8-cm fully covered metal stent. However, in two of the three patients, achieving
fistula dilation was time-consuming and the stent migrated into the peritoneal cavity
in two of the three patients. Recently, we introduced a 6F cystotome (Cysto Gastro
Set; Endo-flex, GmbH, Voerde, Germany) for fistula dilation and an 8-mm, 12-cm covered
stent with a 1-cm uncovered portion at the distal, intrahepatic end (bare-end type,
Niti-S biliary S-type; TaeWoong Medical, Seoul, Korea) ([Fig. 1]) for stenting. Here, we present our experience with four cases of EUS-HG in which
our institutional procedure (6F cystotome and 8-mm, 12-cm covered metal stent) was
used, and evaluate the safety of this procedure.
Fig. 1 Bare-end type Niti-S biliary S-type stent with a 1-cm uncovered portion at the distal
end (red arrow); the remaining portion is fully covered.
Case Reports
Between October 2014 and August 2015, we treated four consecutive cases of malignant
biliary obstruction via EUS-HG with a 6F cystotome and 8-mm, 12-cm covered metal stent.
The indication for EUS-HG was limited to cases with ERCP failure. Procedural consent
was obtained from each patient, and the Institutional Review Board granted permission
to review the patients’ records. The characteristics of these four cases are summarized
in [Table 1].
Table 1
Patient characteristics
|
Case
|
Age (years), Sex
|
Primary disease
|
Surgical procedure
|
Punctured BD
|
Procedure time (min)
|
HGS stent
|
Complication
|
Stent length in the gastric luminal portion (cm)
|
FU period after EUS-HGS (days)
|
Time to stent dysfunction (days)
|
|
Diameter (mm)
|
Length (cm)
|
|
1
|
71 M
|
Gastric cancer
|
Gastrojejunostomy bypass
|
B3
|
29
|
8
|
12
|
Abdominal pain
|
6.6
|
126
|
109
|
|
2
|
71 M
|
Cholangiocarcinoma
|
Resection of extrahepatic bile duct, choledochojejunostomy
|
B3
|
17
|
8
|
12
|
None
|
4.6
|
216
|
32
|
|
3
|
71F
|
Pancreatic cancer
|
None
|
B3
|
35
|
8
|
12
|
None
|
4.8
|
146
|
57
|
|
4
|
91 M
|
Pancreatic cancer
|
None
|
B2
|
29
|
8
|
12
|
None
|
3.1
|
36
|
–
|
M, male; F, female; BD, bile duct; HGS, hepaticogastrostomy; FU, follow-up; EUS, endoscopic
ultrasound
All procedures were performed using a convex-type echoendoscope (GF-UCT260; Olympus
Medical Systems, Tokyo, Japan) and carbon dioxide insufflator. The left intrahepatic
bile duct was punctured from the stomach using a 19G needle (SonoTip; Medi-Globe,
Rosenheim, Germany) under Doppler imaging guidance to avoid any intervening arteries
or veins. After aspirating the bile juice, a small amount of contrast medium was injected
to visualize the biliary tree. Next, a 0.025-in guidewire (VisiGlide; Olympus Medical
Systems, Tokyo, Japan) was inserted into the bile duct through a 19G needle, which
was subsequently exchanged for an ERCP catheter with a 3.5F tip (PR-V110Q; Olympus
Medical Systems, Tokyo, Japan) to avoid guidewire shearing. The guidewire was then
advanced into the common or right intrahepatic bile duct, and the fistula was dilated
using a 6F cystotome (Cysto Gastro Set); subsequently, an electrosurgical high-frequency
generator (ESG-100; Olympus Medical Systems, Tokyo, Japan) with the diathermy current
set to the cut mode (90 W in pulse-cut slow mode) was used. Finally, we placed an
8-mm, 12-cm covered stent with a 1-cm uncovered portion at the distal, intrahepatic
end (bare-end type, Niti-S biliary S-type) from the left intrahepatic bile duct to
the stomach.
Patient 1
A 71-year-old man presented with a malignant biliary stricture and gastric outlet
obstruction due to unresectable advanced gastric cancer, for which he had undergone
endoscopic transpapillary biliary drainage (EBD), gastrojejunostomy bypass, and chemotherapy,
respectively. He was admitted to our institution with an EBD occlusion. ERCP was attempted
to restore the transpapillary biliary drainage, but malignant invasion prevented the
passage of a side-viewing endoscope through the antrum of the stomach. Although we
could reach the ampulla by passing a single-balloon enteroscope (SBE) through the
gastrojejunostomy anastomosis, EBD restoration failed. Therefore, we decided to perform
EUS-HG and successfully placed a bare-end type, Niti-S biliary S-type stent from the
left intrahepatic bile duct (segment 3: B3) to the stomach ([Fig. 2b] and [Fig. 2c]). The patient experienced post-procedural abdominal pain that was relieved in a
few days. He was discharged on day 13 post-EUS-HG. He developed acute cholangitis
on day 109 post-EUS-HG for which endoscopic reintervention was not attempted, as his
performance status had deteriorated because of cancer progression. He died on day
126 post-EUS-HG.
Fig. 2 Fluoroscopic image showing a cystotome over a guidewire inserted into the intrahepatic
bile duct. a Fluoroscopic image showing a metallic stent placed from the left intrahepatic bile
duct to the stomach. b Endoscopic image showing protrusion of the metallic stent from the stomach wall.
c Schema of this case, showing the malignant stenosis (yellow arrow) and the metallic
stent (red arrow) placed from the left intrahepatic bile duct to the stomach.
Patient 2
A 71-year-old man had undergone extrahepatic bile duct resection and choledochojejunostomy
for distal cholangiocarcinoma. He was referred to our department 2 months after surgery
with obstructive jaundice caused by a malignant stenosis of the afferent loop. EBD
using a SBE was attempted, but the endoscope could not be passed through the afferent
loop stenosis. Similarly, a guidewire could not be passed through the stenosis, and
it was therefore impossible to treat the afferent loop stenosis via balloon dilation
or stent placement. Therefore, we decided to perform EUS-HG and successfully placed
a bare-end type, Niti-S biliary S-type stent from the left intrahepatic bile duct
(segment 3: B3) to the stomach ([Fig. 3a–c]). The patient did not experience abdominal pain after the procedure and was discharged
on day 7 post-EUS-HG. He was readmitted for acute cholangitis on day 32 post-EUS-HG;
an esophagogastroduodenoscopy was performed for biliary drainage, and the stent was
found to be occluded with biliary sludge. Accordingly, we inserted an endoscope (Q260J;
Olympus Medical Systems) in the stent opening and aspirated the sludge, thus restoring
the bile flow ([Fig. 3d–f]). Before the patient died due to cancer progression on day 215 post-EUS-HG, acute
cholangitis and stent occlusion due to biliary sludge occurred seven times (every
2 – 4 weeks) and each time, the same treatment was performed.
Fig. 3 a Fluoroscopic image showing the small intestine through the choledochojejunostomy.
b Fluoroscopic image showing a metallic stent placed from the left intrahepatic bile
duct to the stomach. c Schema of this case, showing the malignant afferent loop stenosis (yellow arrow)
and the metallic stent (red arrow) placed from the left intrahepatic bile duct to
the stomach. d – f Endoscopic images at the time of reintervention. The stent was occluded by biliary
sludge, which was removed. The inside of the stent was cleaned.
Patient 3
A 71-year-old woman presented with malignant duodenal stenosis and biliary stricture
resulting from unresectable pancreatic cancer. An EBD for the biliary stricture was
impossible because a side-viewing endoscope could not be passed through the duodenal
stenosis. Therefore, we placed a duodenal stent (Niti-S Pyloric Duodenal D-type stent;
TaeWoong Medical) in the malignant duodenal stenosis and performed EUS-HG for biliary
drainage. We successfully placed a bare-end type, Niti-S biliary S-type stent from
the left intrahepatic bile duct (segment 3: B3) to the stomach ([Fig. 4]). The patient did not experience abdominal pain after the procedure and was discharged
on day 8 post-EUS-HG. She was later readmitted for acute cholangitis on day 57 post-EUS-HG.
We performed cholangiography by inserting an ERCP catheter (PR-V104Q; Olympus Medical
Systems) into the stent using a side-viewing endoscope (JF-260V; Olympus Medical Systems).
The cholangiogram revealed sludge within the stent, which we removed using a retrieval
balloon catheter (Extractor Pro XL; Boston Scientific Japan, Tokyo, Japan; [Fig. 4a,b]). Despite continued chemotherapy, the patient died of cancer progression on day
146 post-EUS-HG.
Fig. 4 a Computed tomography showing a duodenal stent in the malignant duodenal stenosis and
a biliary stent placed from the left intrahepatic bile duct to the stomach. a. Fluoroscopic image at the time of reintervention. The inside of the stent was cleaned
using a retrieval balloon catheter over a guidewire. b Endoscopic image at the time of reintervention. A large amount of sludge was removed
from the inside of the stent.
Patient 4
A 91-year-old man was admitted to our institution with obstructive jaundice caused
by pancreatic cancer. ERCP was initially attempted but failed due to malignant invasion
of the duodenum; accordingly, we decided to perform EUS-HG. Before attempting this
procedure, we placed clips on the esophagogastric junction to facilitate recognition
under fluoroscopic guidance. We punctured the left intrahepatic bile duct (segment
2: B2) using a 19G needle, and placed a bare-end type, Niti-S biliary S-type stent
from the left intrahepatic bile duct (B2) to the stomach ([Fig. 5a – c]). The patient did not experience abdominal pain after the procedure and was discharged
on day 17 post-EUS-HG. He did not experience stent dysfunction during the follow-up
period.
Fig. 5 Fluoroscopic image showing a cystotome over a guidewire inserted into the intrahepatic
bile duct. a Endoscopic image at the time of stent placement, showing a metallic stent protruding
from the stomach wall. b Computed tomography image showing the placement of a metallic stent from the left
intrahepatic bile duct to the stomach.
Discussion
As noted in the introduction, a previous review article reported a relatively high
rate of adverse events associated with EUS-HG, with an average complication rate of
17.0 % [1]. The reported major complications associated with this procedure include cholangitis,
bleeding, stent migration, peritonitis, and bile leakage. We believe that smooth fistula
dilation is necessary to reduce the risk of intraabdominal bile leakage associated
with frequent device exchange and a long procedure time.
At our institution, we have used a 6F cystotome (Cysto Gastro Set) for fistula dilation
during EUS-guided biliary drainage since October 2014. This coaxial device is fitted
with a guidewire and allows safe and rapid fistula dilation. Other institutions have
used a biliary dilation catheter, balloon dilation catheter, and cystotome for fistula
dilation during EUS-guided biliary drainage, as reported in a Japanese multicenter
retrospective study [2]. That retrospective study reported that EUS-guided choledochoduodenostomy was unsuccessful
in two patients treated without a cystotome owing to fistula dilation failure, whereas
EUS-guided biliary drainage, including EUS-HG, was successful in all cases involving
a cystotome. Smooth fistula dilation was possible in all four of our cases; in addition,
we achieved a mean procedure time of 27.5 minutes and did not encounter peritonitis
due to bile leakage in any of our cases. Recently, another study reported the usefulness
of a novel fine-gauge balloon catheter for hepaticogastric fistula dilation [3]. Further studies of safe and useful methods of fistula dilation are required.
According to the literature, the complication of stent migration to the peritoneal
cavity may occur in both the early and late post-EUS-HG phases and might lead to a
very poor prognosis. The literature describes a case in which a 6-cm covered metallic
stent migrated with a fatal outcome, and a case in which an 8-cm covered metallic
stent migrated, necessitating surgical treatment [4]
[5]. Before incorporating a bare-end type, Niti-S biliary S-type stent, we performed
EUS-HG in three patients but two of them experienced stent migration. In one case,
a 7-cm straight plastic stent migrated to the peritoneal cavity on day 2 post-EUS-HG,
necessitating percutaneous drainage; in the other case, an 8-cm covered metallic stent
migrated to the peritoneal cavity during the procedure, necessitating the placement
of an additional metallic stent.
From the above literature and our experiences, we believe that 10-cm or longer stents
should be used to avoid stent migration. In a recent report, severe complications,
including stent migration, did not occur in 12 patients with EUS-HG using a 10-cm
or 12-cm bare-end type, Niti-S biliary S-type stent [6]. Although all of those cases also involved EUS-antegrade stenting for biliary stenosis,
the report suggests that EUS-HG with a 10-cm or longer metallic stent is safe. We
achieved technical success in all cases involving the placement of 12-cm stents, and
none of the patients experienced complications such as stent migration. Moreover,
a recent report described a significantly shorter median stent patency duration in
patients who underwent EUS-HG with a stent length < 3 cm in the luminal portion, relative
to those with a stent length ≥ 3 cm; therefore, we believe that a longer stent should
be used for EUS-HG [7]. In all of our cases, the stent length in the luminal portion exceeded 3 cm.
In addition, the diameter of the stent used in EUS-HG remains controversial. In our
cases, we used an 8-mm stent to avoid stent dysfunction due to granulation of the
hepatic side of the stent, which is caused by intrahepatic bile duct overexpansion.
However, the outcomes achieved with this stent diameter should be compared with outcomes
following the placement of 6-mm and 10-mm stents.
Only a few reports have described endoscopic reintervention after EUS-HG with a metal
stent; these include a case in which the portion of the stent that protruded into
the stomach was trimmed using argon plasma coagulation, and a case of hepaticogastric
fistula in which a metal stent was exchanged while retaining the guidewire and endoscopic
nasobiliary drainage tube [8]
[9]. Of our four patients, three exhibited stent dysfunction and two underwent endoscopic
reintervention (Patients 2 and 3). Successful reintervention was performed by aspirating
biliary sludge from the inside of the stent with a conventional endoscope in Patient
2, and by removing sludge with a retrieval balloon catheter and a side-viewing endoscope
in Patient 3. In Patient 2, acute cholangitis and stent occlusion due to biliary sludge
occurred frequently. Despite the absence of malignant duodenal stenosis, considerable
quantities of food were found in the patient’s stomach at each endoscopic re-intervention.
Delayed gastric emptying was thought to be the cause of frequent stent occlusion,
but prokinetic agents were not effective. An anti-reflux covered metal stent was reported
to be useful for transpapillary biliary drainage in patients with recurrent biliary
metal stent occlusion, and the potential usefulness of this stent type in patients
with EUS-HG should be investigated [10].
In summary, our experiences with the cases described here have led us to conclude
that EUS-HG with a 6F cystotome and an 8-mm, 12-cm covered metal stent is likely safe;
however, further large-scale investigations will be required to confirm our findings.
