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DOI: 10.1055/a-2132-5116
Piercing technique for mucosal hyperplasia at an uncovered part of a partially covered stent after endoscopic ultrasound-guided hepaticogastrostomy
A partially covered self-expandable metal stent (PCSEMS) is preferred in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) to prevent stent dislocation and branch duct occlusion [1] [2]. A PCSEMS with a 10-mm uncovered part on the proximal end (Modified Giobor Stent; Taewoong Medical, Seoul) ([Fig. 1]a) has been used frequently [2] [3]; however, tissue hyperplasia occurs around the uncovered part, leading to recurrent biliary obstruction (RBO) [2] [3]. RBO due to hyperplasia is sometimes hardened with abundant fibrosis, resulting in failed guidewire passage during endoscopic reintervention [3] [4]. Here, we present a novel technique to regain biliary access after EUS-HGS with subsequent hyperplasia with the uncovered portion of the PCSEMS.
A 67-year-old male with a history of distal gastrectomy with Roux-en-Y reconstruction was admitted due to jaundice. The patient had undergone EUS-HGS with the PCSEMS for biliary obstruction due to lymph node metastasis 8 months before admission ([Fig. 1]b). To relieve jaundice, reintervention via the distal end of the PCSEMS was performed. A cannulation catheter was inserted from the distal end of the PCSEMS, but a 0.035-inch guidewire (Jagwire; Boston Scientific, Natick, Massachusetts, United States) could not be advanced beyond the PCSEMS. The uncovered part of the PCSEMS was not imaged by contrast medium injection, indicating a complete RBO due to hyperplasia ([Fig. 2]). Next, a stone extraction balloon was inflated inside the PCSEMS to allow passage of the guidewire through the center of the PCSEMS ([Fig. 3]). However, the hyperplasia was too stiff. Finally, a “piercing technique” using the stiff back end of the guidewire [5] was performed, which allowed the guidewire to smoothly advance the stricture ([Fig. 4], [Video 1]). After dilating the uncovered part with an 8-mm balloon dilator, a dedicated plastic stent was successfully deployed through the PCSEMS ([Fig. 5]). The patient’s jaundice resolved after endoscopic revision and was discharged 6 days after admission.
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Publication History
Received: 30 April 2023
Accepted after revision: 02 June 2023
Article published online:
01 September 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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