EUS-guided hepaticogastrostomy as a gateway to intermittent access for biliary leak management

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.

Fig. 1 Abdominal computed tomography revealing a large subhepatic contrast leak upon injection through the percutaneously inserted biliary drain.

Fig. 2 Fluoroscopic image showing successful endoscopic ultrasound-guided access to the left hepatic duct using a 19-gauge needle and 0.035-inch guidewire. A linear contrast opacification can be appreciated just below the liver, compatible with the biliary leak (arrowheads).

Fig. 3 Fluoroscopic image revealing distal migration of the self-expandable metal stent (SEMS) into the small bowel lumen, while another fully covered SEMS is being placed into the left bile duct, creating an EUS-guided hepaticogastrostomy. Both the migrated SEMS and double-pigtail stent were scheduled for double-balloon enteroscopy-assisted retrieval after completion of endoscopic biliary leak treatment.

Video 1 Endoscopic ultrasound-guided hepaticogastrostomy for an anastomotic biliary leak.

Fig. 4 Revision 2 weeks after the index procedure and replacement of the fully covered self-expandable metal stent by a 10-cm double-pigtail stent.

Fig. 5 Second revision after 3 months showing complete resolution of the biliary leak, after which two new double pigtails were placed ultimately to be removed after 3 months.

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.

Endoscopy_UCTN_Code_CPL_1AK_2AI

Publication History

Article published online:
27 January 2021

• 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.