Endoscopy
DOI: 10.1055/s-0043-116379
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Simultaneous duodenal stenting and endoscopic ultrasound-guided hepaticogastrostomy using a forward-oblique view echoendoscope

Tanyaporn Chantarojanasiri1, 2, Hiroyuki Isayama1, Yousuke Nakai1, Saburo Matsubara1, Suguru Mizuno1, Hirofumi Kogure1, Kazuhiko Koike1
  • 1Department of Gastroenterology, the University of Tokyo, Tokyo, Japan
  • 2Department of Internal Medicine, Police General Hospital, Bangkok, Thailand
Further Information

Publication History

Publication Date:
05 September 2017 (eFirst)

A 65-year old man with advanced pancreatic cancer with a combination of malignant biliary obstruction and gastric outlet obstruction was referred to our hospital. Given the presence of periampullary cancerous lesions, the endoscopic placement of a duodenal stent and endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) were performed simultaneously, using a single convex-array echoendoscope with a forward-oblique view (EG-580T; Fujifilm, Tokyo, Japan; [Fig. 1]). A partially covered metal duodenal stent (Niti-S COMVI; Taewoong Medical, Gimpo, Korea) was placed under fluoroscopic and endoscopic guidance ([Fig. 2], [Video 1]). This was followed, without scope exchange, by EUS-HGS: a long partially covered metal stent (modified GIOBOR, Taewoong Medical) was successfully placed [1] from the B3 intrahepatic duct to the stomach under EUS, endoscopic, and fluoroscopic guidance ([Fig. 3], [Video 2]). The total procedure time was 38 minutes.

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Fig. 1 The new forward-oblique view convex-array echoendoscope, with 40° forward viewing direction.
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Fig. 2 Duodenal stent placement, using the new forward-oblique view echoendoscope, in a patient with advanced pancreatic cancer and a combination of malignant biliary obstruction and gastric outlet obstruction.

Video 1 Part 1. Simultaneous duodenal stenting and endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using a forward-oblique view echoendoscope. A partially covered metal duodenal stent is placed under fluoroscopic and endoscopic guidance.

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Fig. 3 Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) performed, without scope exchange, immediately after the duodenal stent placement shown in [Fig. 2]. The tip of the echoendoscope and the puncture site were seen endoscopically, enabling stent insertion and deployment under direct visualization.

Video 2 Part 2. Simultaneous duodenal stenting and endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). In the subsequent (EUS-HGS), done without scope exchange, a long partially covered metal stent is deployed from the B3 intrahepatic duct to the stomach under EUS, endoscopic, and fluoroscopic guidance.

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Combined malignant biliary obstruction and gastric outlet obstruction are not rare in advanced pancreatic cancer and EUS-guided biliary drainage, especially EUS-HGS [2], is increasingly reported because of its better patency than transpapillary biliary drainage [3]. Conventionally, enteric stents are placed using a forward-viewing endoscope and EUS-guided biliary drainage by an oblique-viewing echoendoscope. A single-session dual-stent placement using two endoscopes has been described [4].

This new echoendoscope with a forward-oblique view has a 3.8-mm operating channel, and has a 40° forward viewing direction with 140° field of view compared to the 55° viewing direction and 100° field of view in the conventional oblique-viewing echoendoscope [5]. This enables the direct visualization of both the enteric stricture and the enteric stent deployment, and also helps hepaticogastrostomy with EUS-guided biliary drainage stent deployment with endoscopic guidance. Thus a single echoendoscope can be used to place a duodenal stent and an EUS-guided biliary drainage stent.

In conclusion, the simultaneous placement of a duodenal stent and EUS-HGS is feasible using the new forward-oblique view echoendoscope, facilitating shorter procedure time without the need for scope exchange.

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