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DOI: 10.1055/a-1327-1849
EUS-guided hepaticogastrostomy as a gateway to intermittent access for biliary leak management
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Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HPG) is still unfairly confined to palliation of advanced malignancies. However, this technique might be of significant help in benign indications, providing effective and safe long-term access to the biliary tree and facilitating the definitive treatment of biliary diseases [1] [2] [3] [4].
A 65-year-old patient with a history of pancreaticoduodenectomy was referred for a biliary leak following a recent redo hepaticojejunostomy ([Fig. 1]). Enteroscopy-directed endoscopic retrograde cholangiopancreatography (ERCP) was performed, with confirmation of the biliary leak and insertion of a 7-Fr double-pigtail stent. Unfortunately, this stent migrated distally. With the left-sided bile duct dilation and surgically altered anatomy in mind, EUS-guided antegrade stenting was attempted. The left main hepatic duct was accessed using a 19G needle ([Fig. 2]); the guidewire was advanced into the small bowel, after which the trajectory was consolidated using a 6-Fr cystotome, and a fully covered self-expandable metal stent (FCSEMS) was placed. However, this stent migrated into the small bowel, and therefore an EUS-guided HPG was performed over the same guidewire ([Fig. 3]) in an effort to provide immediate biliary drainage together with long-term access ([Video 1]). Considering the benign indication, an FCSEMS (10 × 80 mm) was used for EUS-guided HPG. A revision was performed 2 weeks later, with extraction of the FCSEMS and replacement with a double-pigtail stent (10 Fr × 10 cm), bridging the fistula ([Fig. 4]). A new revision was performed 3 months later that showed complete resolution of the biliary leak ([Fig. 5]), after which two double pigtails were inserted in similar fashion, to be finally extracted in 3 months’ time.
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Video 1 Endoscopic ultrasound-guided hepaticogastrostomy for an anastomotic biliary leak.
Quality:
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Our case illustrates that in patients with benign indications and impossible/failed retrograde access, EUS-guided HPG may ensure an effective long-term gateway to definitive endoscopic treatment of biliary diseases. In this context, double-pigtail stents can provide secure drainage and long-term patency as well as minimize the risk of migration.
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Publication History
Article published online:
27 January 2021
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References
- 1 Miranda-García P, Gonzalez JM, Tellechea JI. et al. EUS hepaticogastrostomy for bilioenteric anastomotic strictures: a permanent access for repeated ambulatory dilations? Results from a pilot study. Endosc Int Open 2016; 4: E461-E465 DOI: 10.1055/s-0042-103241.
- 2 Vanella G, Bronswijk M, van Malenstein H. et al. EUS-guided intrahepatic access for retrograde, antegrade or transgastric biliary drainage: indications, efficacy and safety from an 8-year tertiary center experience. Gastrointestinal Endoscopy 2020; 49: AB93
- 3 Nakai Y, Kogure H, Isayama H. et al. Endoscopic ultrasound-guided biliary drainage for benign biliary diseases. Clin Endosc 2019; 52: 212-219 DOI: 10.5946/ce.2018.188.
- 4 Okuno N, Hara K, Mizuno N. et al. Advanced technique for biliary stricture diagnosis using endoscopic ultrasound (EUS)-guided hepaticogastrostomy. Endoscopy 2017; 49: E60-E61 DOI: 10.1055/s-0042-123498.