Rescue technique after endoscopic ultrasound-guided hepaticogastrostomy stent dislocation

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been indicated after failed endoscopic retrograde cholangiopancreatography (ERCP). Critical adverse events such as stent migration or dislocation can occur during EUS-HGS [1] [2] [3]. If a fistula is not formed after the occurrence of these adverse events, an alternative biliary drainage technique is required, such as percutaneous transhepatic biliary drainage and endoscopic suture of the anastomotic defect left behind after the EUS-HGS stent. A novel endoscopic suture using an endoloop and endoclips has recently been reported for use after upper gastrointestinal perforations [4] [5]. We herein describe the successful use of these techniques for endoscopic treatment after EUS-HGS stent dislocation.

A 57-year-old man was admitted with obstructive jaundice due to inoperable pancreatic cancer. Because the second part of the duodenum was obstructed, EUS-HGS was performed using a partially covered self-expandable metal stent. However, abdominal pain and recurrence of obstructive jaundice were noted 5 days later, and CT revealed dislocation of the stent ([Fig. 1]). After insertion of the duodenoscope in endoscopic re-intervention, attempts to insert the guidewire into the intrahepatic bile duct were unsuccessful ([Fig. 2]). Therefore, EUS-guided choledochoduodenostomy was performed. The EUS-HGS stent was then removed. A single-channel endoscope was inserted to perform endoscopic suturing. After locating the anastomotic defect left behind after the EUS-HGS stent ([Fig. 3]), an endoloop was grasped by the tip of the endoscope from the outside and advanced to this site along with the endoscope. The endoloop was placed in the open state along the edge of the defect and anchored at multiple sites by clips that allow repeated opening and closing ([Fig. 4]). Finally, the anastomotic defect was sutured by tightening the fixed endoloop ([Fig. 5] ; [Video 1]). These procedures were successfully performed without any adverse events.

Fig. 1 Computed tomography image shows dislocation of an endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) stent.

Fig. 2 The EUS-HGS stent has become dislocated from the intrahepatic bile duct and leakage of contrast medium into the abdominal cavity is observed.

Fig. 3 The anastomotic defect is visible after removal of the stent.

Fig. 4 An endoloop is placed in the open state along the edge of the defect and anchored at multiple sites by clips that allow repeated opening and closing.

Fig. 5 Successful suturing of the anastomotic defect.

Novel endoscopic suture using an endoloop and endoclips successfully deployed for endoscopic treatment after dislocation of an endoscopic ultrasound-guided hepaticogastrostomy stent.Video 1

In conclusion, the present technique may be useful for troubleshooting during EUS-HGS, particularly in the case of stent dislocation.

Endoscopy_UCTN_Code_CPL_1AL_2AD

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Dell’Anna G, Ogura T, Vanella G. et al. Endoscopic ultrasound guided biliary interventions. Best Pract Res Clin Gastroenterol 2022;
• 2 Vedantam S, Amin S. Endoscopic ultrasound-guided biliary interventions in liver disease. Clin Liver Dis 2022; 26: 101-114
• 3 Ogura T, Higuchi K. Technical review of developments in endoscopic ultrasound-guided hepaticogastrostomy. Clin Endosc 2021; 54: 651-659
• 4 Abe S, Oda I, Mori G. et al. Complete endoscopic closure of a large gastric defect with endoloop and endoclips after complex endoscopic submucosal dissection. Endoscopy 2015; 47: E374-E375
• 5 Ego M, Abe S, Nonaka S. et al. Endoscopic closure utilizing endoloop and endoclips after gastric endoscopic submucosal dissection for patients on antithrombotic therapy. Dig Dis Sci 2021; 66: 2336-2344

Publication History

Article published online:
11 December 2023