Endoscopy 2019; 51(01): E12-E13
DOI: 10.1055/a-0756-7341
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Endoscopic ultrasound-guided hepaticogastrostomy combined with novel uncovered metal stent

Takeshi Ogura
2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
,
Nobu Nishioka
2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
,
Akira Miyano
2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
,
Rieko Kamiyama
2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
,
Kazuhide Higuchi
2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
› Author Affiliations
Further Information

Corresponding author

Takeshi Ogura, MD
2nd Department of Internal Medicine
Osaka Medical College
2-7 Daigakuchou
Takatsukishi
Osaka 569-8686
Japan   
Fax: +81-72-6846532   

Publication History

Publication Date:
07 November 2018 (online)

 

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been developed as an alternative method for biliary drainage after failed endoscopic retrograde cholangiopancreatography (ERCP) [1]. EUS-HGS may be indicated for patients with advanced disease stages [2] [3]. However, following recent developments in chemotherapy, such as FOLFIRINOX (folinic acid + fluorouracil + irinotecan + oxaliplatin) [4], longer survival may be obtained; therefore, longer stent patency is clearly required.

Recently, EUS-HGS combined with antegrade stent placement has been reported for this purpose [5]. For this technique, to prevent stent dislocation or misplacement due to stent shortening, a laser-cut-type, uncovered, metal stent may be preferred. However, if the angle of bile duct axis is acute, stent expansion may be insufficient due to low radial force. Recently, a novel, uncovered, metal stent has become available in Japan ([Fig. 1]). This stent has uncovered flexible cells but maintains a strong radial force. Stent deployment is therefore possible along the bile duct axis. Herein, we describe the technical tips for EUS-HGS with antegrade stent placement using this novel stent.

Zoom Image
Fig. 1 The biliary uncovered metal stent (HILZO STENT, BCM Co., Ltd, Gyeonggi-do, South Korea). This stent has uncovered flexible cells resulting in low axial force but maintaining strong radial force.

A 78-year-old man was admitted to our hospital with obstructive jaundice due to gastric cancer. The patient had undergone gastrojejunostomy for gastric outlet obstruction 6 months earlier. Therefore, EUS-guided access was attempted as a drainage method.

First, the intrahepatic bile duct was punctured using a 19-gauge fine-needle aspiration needle, and the guidewire was placed. Then, an ERCP catheter was inserted into the biliary tract, and the contrast medium was injected. On cholangiography, bile duct obstruction was seen in the middle common bile duct with a relatively tortuous axis ([Fig. 2]). Therefore, a flexible uncovered metal stent (10 mm × 8 cm) was deployed in an antegrade fashion ([Fig. 3]). Finally, EUS-HGS was performed using a partially covered metal stent ([Fig. 4]).

Zoom Image
Fig. 2 Bile duct obstruction was seen in the middle common bile duct with a relatively tortuous bile duct axis.
Zoom Image
Fig. 3 Antegrade stent deployment was performed for the novel uncovered metal stent.
Zoom Image
Fig. 4 Endoscopic ultrasound-guided hepaticogastrostomy was performed using a partially covered metal stent.

The following day, full expansion of the flexible metal stent was confirmed on computed tomography ([Fig. 5]).

Zoom Image
Fig. 5 Full expansion of the flexible metal stent was confirmed on computed tomography.

Video 1 Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) combined with antegrade placement of a novel uncovered metal stent. The intrahepatic bile duct was punctured using a 19-gauge fine-needle aspiration needle, and the contrast medium was injected. The guidewire was then inserted into the biliary tract. An endoscopic retrograde cholangiopancreatography catheter was inserted, and more contrast medium was injected. After the guidewire was advanced into the intestine across the obstruction site, the novel uncovered metal stent was deployed. Finally, EUS-HGS was successfully performed.


Quality:

A flexible stent may be clinically useful, not only for multi-stenting in a through-the-stent technique under ERCP guidance, but also in EUS-HGS combined with antegrade stent placement.

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Competing interests

None

  • References

  • 1 Boulay BR, Lo SK. Endoscopic ultrasound-guided biliary drainage. Gastrointest Endosc Clin N Am 2018; 28: 171-185
  • 2 Baars JE, Kaffes AJ, Saxena P. EUS-guided biliary drainage: a comprehensive review of the literature. Endosc Ultrasound 2018; 7: 4-9
  • 3 Ogura T, Higuchi K. Technical tips for endoscopic ultrasound-guided hepaticogastrostomy. World J Gastroenterol 2016; 22: 3945-3951
  • 4 Conroy T, Desseigne F, Ychou M. et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 2011; 364: 1817-1825
  • 5 Ogura T, Kitano M, Takenaka M. et al. Multicenter prospective evaluation study of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting (with video). Dig Endosc 2018; 30: 252-259

Corresponding author

Takeshi Ogura, MD
2nd Department of Internal Medicine
Osaka Medical College
2-7 Daigakuchou
Takatsukishi
Osaka 569-8686
Japan   
Fax: +81-72-6846532   

  • References

  • 1 Boulay BR, Lo SK. Endoscopic ultrasound-guided biliary drainage. Gastrointest Endosc Clin N Am 2018; 28: 171-185
  • 2 Baars JE, Kaffes AJ, Saxena P. EUS-guided biliary drainage: a comprehensive review of the literature. Endosc Ultrasound 2018; 7: 4-9
  • 3 Ogura T, Higuchi K. Technical tips for endoscopic ultrasound-guided hepaticogastrostomy. World J Gastroenterol 2016; 22: 3945-3951
  • 4 Conroy T, Desseigne F, Ychou M. et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 2011; 364: 1817-1825
  • 5 Ogura T, Kitano M, Takenaka M. et al. Multicenter prospective evaluation study of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting (with video). Dig Endosc 2018; 30: 252-259

Zoom Image
Fig. 1 The biliary uncovered metal stent (HILZO STENT, BCM Co., Ltd, Gyeonggi-do, South Korea). This stent has uncovered flexible cells resulting in low axial force but maintaining strong radial force.
Zoom Image
Fig. 2 Bile duct obstruction was seen in the middle common bile duct with a relatively tortuous bile duct axis.
Zoom Image
Fig. 3 Antegrade stent deployment was performed for the novel uncovered metal stent.
Zoom Image
Fig. 4 Endoscopic ultrasound-guided hepaticogastrostomy was performed using a partially covered metal stent.
Zoom Image
Fig. 5 Full expansion of the flexible metal stent was confirmed on computed tomography.