Keywords
EUS - hepaticogastrostomy - maldeployed stent
A 69-year-old lady with pancreatic head malignancy with obstructive jaundice and duodenal bulb infiltration underwent endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) ([Fig. 1]). The procedure was performed under general anesthesia, and a linear EUS examination (GF UCT 180, Olympus, Tokyo, Japan) was performed through proximal stomach. A segment 3 duct was punctured with a fine needle aspiration (FNA) needle (19G, Expect Slimline, Boston Scientific, Massachusetts, United States), guidewire (0.025, VisiGlide, Olympus, Tokyo, Japan) was negotiated into proximal bile duct, followed by dilatation with 6Fr cystotome with endocut mode (ERBE VIOD300, Tübingen, Germany) and 4 mm biliary balloon (Hurricane, 4 mm × 4 cm, Boston Scientific, Cork, Ireland). During stent placement, the proximal end of stent (10 mm × 10 cm, partially covered Hanarostent biliary NC, M.I.Tech, Korea) got maldeployed inside the peritoneal cavity, along with loss of guidewire access. Multiple attempts to cannulate the proximal end of stent through the puncture site were unsuccessful. Considering the morbid nature of potential surgical option, an EUS-guided rescue technique was performed. The body of previously maldeployed stent was punctured with an EUS-guided 19 G needle (transgastric route) followed by guidewire negotiation in the common hepatic duct ([Fig. 2]). Sequential dilatation of gastric puncture site and stent was performed with 6 Fr cystotome, 4 mm hurricane balloon, and 10 Fr cystotome ([Fig. 3]). A fully covered self-expandable metallic stent (SEMS; 10 mm × 8 cm WallFlex, biliary; Boston Scientific, Massachusetts, United States) was placed with the distal end in the previously maldeployed stent and the proximal end inside the gastric lumen and free flow of bile could be established ([Fig. 4]). A double pigtail plastic stent was placed inside the SEMS for anchoring. A duodenal SEMS was also placed in the same setting ([Figs. 5] and [6]). The patient was extubated and shifted to ward ([Video 1]). The patient developed segmental cholangitis (Segment 2) and liver abscess during follow-up, which responded to intravenous antibiotics and single-time aspiration of liver abscess ([Fig. 7]). The patient has been under follow-up for 6 months without any biliary complications.
Fig. 1 Baseline CECT abdomen and MRCP. CECT, contrast-enhanced computed tomography; MRCP, magnetic resonance cholangiopancreatography.
Fig. 2 Guidewire placement through maldeployed stent.
Fig. 3 Balloon dilatation of new tract and stent.
Fig. 4 New fully covered stent (lower arrow) through maldeployed stent (upper arrow) (stent in-stent).
Fig. 5 Animated illustration of the stent in-stent.
Fig. 6 Duodenal SEMS and hepaticogastrostomy stent. SEMS, self-expandable metallic stent.
Video 1 Maldeployed hepaticogastrostomy stent—rescue by a novel technique.
Qualität:
Fig. 7 Post-procedure CECT abdomen showing maldeployed and second fully covered stent. CECT, contrast-enhanced computed tomography.
Stent maldeployment has been reported as a serious complication during EUS-HGS.[1] Stent placement through the end of maldeployed stent is the most commonly used rescue technique.[2] Loss of proximal end in the peritoneal cavity may lead to challenging situations,[3] which may be rescued by puncture of the maldeployed stent with the placement of additional stent.
