Endoscopic ultrasound-guided hepaticojejunostomy for drainage of the right posterior hepatic duct enabled total liver drainage

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.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Vienne A, Hobeika E, Gouya H. et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc 2010; 72: 728-735
• 2 Takahashi E, Fukasawa M, Sato T. et al. Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry. World J Gastroenterol 2015; 21: 4946-4953

Publikationsverlauf

Artikel online veröffentlicht:
16. Januar 2023