In a patient with unresectable malignant hilar biliary obstruction (MHBO), drainage
of as much liver volume as possible is recommended [1]
[2]. However, the retrograde approach is difficult owing to anatomic factors or the
extent of stenosis, particularly in the right posterior hepatic duct. We report a
case in which endoscopic ultrasound-guided hepaticojejunostomy (EUS-HJS) of the right
posterior hepatic duct allowed total liver drainage ([Video 1]).
Video 1 Total liver drainage without the need for percutaneous drainage was successfully
performed using transanastomotic biliary drainage combined with endoscopic ultrasound-guided
hepaticojejunostomy of the right posterior hepatic duct using a forward-viewing echoendoscope.
A 59-year-old woman underwent subtotal stomach-preserving pancreatoduodenectomy for
ampullary carcinoma of the duodenum, and MHBO (Bismuth type 3a) due to recurrent tumor
at the cholangiojejunostomy anastomosis was clinically suspected. Therefore, retrograde
drainage was performed. A colonoscope was inserted into the anastomosis site ([Fig. 1]). The left hepatic duct and right anterior hepatic duct were visualized using contrast
agent and guidewires were placed; however, the right posterior hepatic duct was completely
obstructed and could not be approached ([Fig. 2]). Therefore, we decided that retrograde drainage was indicated for the left hepatic
duct and right anterior hepatic duct, and EUS-HJS for the right posterior hepatic
duct.
Fig. 1 a In a 59-year-old woman with previous subtotal stomach-preserving pancreatoduodenectomy
for ampullary carcinoma of the duodenum, a colonoscope was inserted into the cholangiojejunostomy
anastomosis. Endoscopically, anastomotic stenosis (arrow) caused by recurrent tumor
was observed. b A catheter was inserted for contrast enhancement.
Fig. 2 a, b The left hepatic duct and right anterior hepatic duct were successfully enhanced
and guidewires were placed. However, the right posterior hepatic duct was completely
obstructed and could not be enhanced.
First, fully covered self-expandable metal stents (FCSEMSs, 6 mm × 6 cm) (EGIS braided
6; S&G Biotech Inc., Yongin-si, Korea) were placed retrogradely in the left hepatic
duct and right anterior hepatic duct ([Fig. 3]). Then, a forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan) was
inserted, and the dilated right posterior hepatic duct, infraportal type, was shown
near the anastomosis. This was punctured with a 19-gauge needle (EZ Shot 3 Plus; Olympus,
Tokyo, Japan) and confirmed as the dilated right posterior hepatic duct by contrast
enhancement ([Fig. 4]). The fistula was dilated with an electrocautery dilator (Fine025; Medico’s Hirata,
Osaka, Japan), after which a FCSEMS (6 mm × 6 cm; Hanarostent Biliary Full Cover Benefit;
Boston Scientific, Tokyo, Japan) was placed ([Fig. 5]).
Fig. 3 a, b Fully covered self-expandable metal stents (6 mm × 6 cm) were placed retrogradely
in the left hepatic duct and right anterior hepatic duct in a side-by-side manner.
Fig. 4 a The dilated right posterior hepatic duct was shown near the anastomosis. b The dilated right posterior hepatic duct was punctured with a 19-gauge needle. c The dilated right posterior hepatic duct was confirmed by contrast enhancement and
a guidewire was placed.
Fig. 5 a–c A fully covered self-expandable metal stent (6 mm × 6 cm) was placed in the completely
obstructed right posterior hepatic duct. d Computed tomography confirmed that total liver drainage was achieved after the procedure.
No adverse events occurred postoperatively, and the patient was discharged 2 days
later. No stent dysfunction was observed before death, which occurred 47 days after
the procedure owing to exacerbation of the underlying recurrent disease.
EUS-HJS is useful as rescue drainage for MHBO in cases where the right posterior hepatic
duct is unapproachable retrogradely.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online. Processing charges apply (currently EUR
375), discounts and wavers acc. to HINARI are available.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
