Endoscopy 2019; 51(10): E297-E298
DOI: 10.1055/a-0915-1718
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© Georg Thieme Verlag KG Stuttgart · New York

Re-intervention for recurrent biliary obstruction after endoscopic ultrasound hepaticogastrostomy with partially covered self-expandable metal stent

Kosuke Maehara
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Susumu Hijioka
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Shih Yea Sylvia Wu
2   Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
,
Akihiro Ohba
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yasunari Sakamoto
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Takuji Okusaka
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
,
Yutaka Saito
2   Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
› Author Affiliations
Further Information

Publication History

Publication Date:
23 May 2019 (online)

The use of the endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) method for malignant biliary stricture has increased. A partially covered self-expandable metal stent (PCSEMS) is often selected for the procedure, and re-intervention is challenging because of the long length of stent protrusion inside the stomach. Several re-intervention methods, including trimming and stent penetration using electrical devices, have been reported [1] [2] [3] [4]; however, the complexity and time-consuming nature of these procedures pose limitations. Here, we report the simplest of novel re-intervention methods for PCSEMS dysfunction after an EUS-HGS.

A 65-year-old woman with unresectable pancreatic cancer and duodenal obstruction underwent EUS-HGS using a PCSEMS (Niti-S biliary S-type; 8-mm × 10-cm covered stent with a 1-cm uncovered portion; Taewoong Medical, Seoul, South Korea). After 8 months had passed, recurrent biliary obstruction occurred due to bile duct hyperplasia at the stent edge ([Fig. 1]). Stent removal with a grasping forceps was not possible because it was firmly anchored by the overgrown tissue. Inserting a guidewire and a catheter parallel to the stent to access the bile duct was also not feasible.

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Fig. 1 Recurrent biliary obstruction after endoscopic ultrasound-guided hepaticogastrostomy shown on: a computed tomography image; b endoscopic view.

We therefore penetrated the stent mesh close to the stomach wall with a guidewire (Visiglide2; Olympus, Tokyo, Japan) and a catheter (Tandem XL ERCP Cannula; Boston Scientific Corporation, Marlborough, Massachusetts, USA). These devices were advanced into the stent ([Fig. 2]), and bypassed the stricture allowing access to the bile duct. The biliary stricture and the stent mesh, at the entry point of the wire and catheter, were dilated with a balloon catheter (REN; 8-mm wide; Kaneka Medix Corporation, Tokyo). A fully covered SEMS (Niti-S biliary S-type; 6-mm × 8-cm long covered stent; Taewoong Medical) was threaded through the dilated tract and successfully deployed ([Fig. 3], [Video 1]). This procedure was completed without any adverse events.

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Fig. 2 Endoscopic view showing a 0.025-inch guidewire and a catheter penetrating through the mesh of the previously placed hepaticogastrostomy stent near the stomach wall.
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Fig. 3 A fully covered self-expandable metal stent (arrow) is positioned through the previously placed stent, as shown on: a endoscopic view; b computed tomography (CT) image; c reconstructed CT image.

Video 1 The video shows a novel re-intervention method for recurrent biliary obstruction after endoscopic ultrasound-guided hepaticogastrostomy with a partially covered self-expandable metal stent.


Quality:

This novel re-intervention method involving penetration of the stent mesh near the stomach wall is simple, safe, and efficient.

Endoscopy_UCTN_Code_CPL_1AL_2AD

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  • References

  • 1 Yane K, Katanuma A, Maguchi H. et al. Successful re-intervention with metal stent trimming using argon plasma coagulation after endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2014; 46: E391-E392
  • 2 Hamada T, Nakai Y, Isayama H. et al. Trimming a covered metal stent during hepaticogastrostomy by using argon plasma coagulation. Gastrointest Endosc 2013; 78: 817
  • 3 Minaga K, Takenaka M, Okamoto A. et al. Reintervention for stent occlusion after endoscopic ultrasound-guided hepaticogastrostomy with novel use of a precut needle-knife. Endoscopy 2018; 50: E153-E154
  • 4 Ogura T, Masuda D, Takeuchi T. et al. Simplified reintervention method of EUS-guided hepaticogastrostomy stent obstruction. Gastrointest Endosc 2016; 83: 831