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CC BY 4.0 · Endoscopy 2023; 55(S 01): E757-E758
DOI: 10.1055/a-2086-2062
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Rescue using NOTES during endoscopic ultrasound-guided hepaticogastrostomy, after maldeployment of fully covered self-expandable metal stent

Xiaohua Ye 
1   Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, P. R. China
,
Xiaoju Su
2   Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, P. R. China
,
Ting Yang
2   Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, P. R. China
,
Bo Li
2   Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, P. R. China
,
Lei Wang
2   Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, P. R. China
› Author Affiliations

Supported by: National Natural Science Foundation of China http://dx.doi.org/10.13039/501100001809 82170656 Supported by: Natural Science Foundation of Zhejiang Province http://dx.doi.org/10.13039/501100004731 LQ19H030003
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A 56-year-old man was admitted to our hospital with obstructive jaundice caused by extrahepatic cholangiocarcinoma that developed from a congenital choledochal cyst ([Fig. 1]). Endoscopic retrograde cholangiopancreatography was hampered by ampullary effacement caused by malignant invasion. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy was therefore attempted using an 8-cm fully covered self-expandable metal stent (FCSEMS) (Boston Scientific, Marlborough, Massachusetts, USA).

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Fig. 1 Imaging findings of extrahepatic cholangiocarcinoma developing from a congenital choledochal cyst.

A linear echoendoscope was advanced to the stomach. The intrahepatic bile duct (B3) was punctured with a 19G aspiration needle ([Fig. 2]). A 0.035-inch guidewire was subsequently inserted via the aspiration needle. Following release of the FCSEMS, cholangiography revealed maldeployment of the proximal flange of the stent into the abdominal cavity.

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Fig. 2 Endoscopic ultrasound (EUS) view of puncture of the dilated intrahepatic bile duct.

We then switched the echoendoscope to a gastroscope ([Fig. 3]). The entire thickness of the gastric wall was incised using a DualKnife in the puncture location. The gastroscope was further inserted into the abdominal cavity to visualize the position of the FCSEMS. Repositioning of the FCSEMS was achieved by using a foreign-body forceps to pull out the proximal flange through the incision in the gastric wall. Finally, the defect in the gastric wall was sutured with endoclips ([Video 1]). Cholangiography confirmed that the FCSEMS was in place. The post-procedure period was uneventful and the bilirubin level was improved.

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Fig. 3 A gastroscope did not detect the proximal flange of the stent in the lumen of the gastroesophageal junction.

Video 1 Following maldeployment of the proximal flange of the stent into the abdominal cavity during endoscopic ultrasound-guided hepaticogastrostomy, transgastric natural orifice transluminal endoscopic surgery (NOTES) was used as a rescue procedure.

Stent maldeployment during EUS-guided hepaticogastrostomy is a significant adverse event that needs to be immediately managed [1]. The rescue approach described here, which employs transgastric natural orifice transluminal endoscopic surgery (NOTES), avoids the need for emergency surgery, as well as sacrifice of the stent, hence saving on cost.

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Competing interests

The authors declare that they have no conflict of interest.

  • Reference

  • 1 Ligresti D, Amata M, Granata A. et al. Salvage procedure following lumen-apposing metal stent maldeployment during endoscopic ultrasound-guided biliary drainage. Endoscopy 2018; 50: E190-E191
    Thieme ConnectPubMedSearch in Google Scholar

Corresponding author

Lei Wang, MD
Department of Gastroenterology, Digestive Endoscopy Center
Changhai Hospital, Naval Medical University
Shanghai 200433
P. R. China   

Publication History

Article published online:
26 May 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • Reference

  • 1 Ligresti D, Amata M, Granata A. et al. Salvage procedure following lumen-apposing metal stent maldeployment during endoscopic ultrasound-guided biliary drainage. Endoscopy 2018; 50: E190-E191
    Thieme ConnectPubMedSearch in Google Scholar

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Zoom Image
Fig. 1 Imaging findings of extrahepatic cholangiocarcinoma developing from a congenital choledochal cyst.
Zoom Image
Fig. 2 Endoscopic ultrasound (EUS) view of puncture of the dilated intrahepatic bile duct.
Zoom Image
Fig. 3 A gastroscope did not detect the proximal flange of the stent in the lumen of the gastroesophageal junction.