Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with antegrade stenting
has recently been applied to malignant biliary obstruction including in surgically
altered anatomy [1]
[2]. This method has reduced the rate of bile leakage, which is expected to prevent
stent migration [3], and prolong time to stent dysfunction [4]. In surgically altered anatomy, there is a concern that a covered self-expandable
metal stent (SEMS) can cause the other hepatic ducts to occlude as the distance between
the anastomosis and bifurcation is small. The commonly used uncovered SEMS may result
in tumor ingrowth. We report successful EUS-HGS with antegrade stenting using a new
fully covered multi-hole SEMS (HANARO Biliary Multi-Hole NEO; M.I.Tech Co Ltd., Pyeongtaek,
South Korea) ([Fig. 1]) for malignant biliary obstruction in surgically altered anatomy.
Fig. 1 New fully covered multi-hole metal stent. This stent is made from nitinol with a fixed
hook and cross-wired structure, which is fully covered with a silicone membrane and
a multi-hole of 1.8 mm in diameter.
A 51-year-old man, who previously underwent subtotal stomach-preserving pancreatoduodenectomy
for distal cholangiocarcinoma (pT2N1M0 pStage IIB) and subsequent chemotherapy, visited
our department for obstructive jaundice. He was diagnosed with a tumor recurrence
through computed tomography ([Fig. 2]) and endoscopic ultrasound ([Fig. 3]). The procedure involved a B3 puncture using a 22-gauge needle and 0.018-inch guidewire,
fistula dilation, and catheter insertion followed by the placement of two guidewires.
Fluoroscopy showed that the left and right hepatic ducts in the bifurcation were not
separated. Thereafter, the two guidewires and catheter were successfully advanced
to the jejunum over the anastomosis, and we confirmed the anastomotic obstruction.
Finally, an 8-mm fully covered multi-hole SEMS was placed from the jejunum into the
left hepatic duct followed by the placement of a 7 Fr plastic stent into the EUS-HGS
fistula ([Video 1]). After the procedure, obstructive jaundice improved. The placement of a covered
SEMS for malignant biliary obstruction in surgically altered anatomy is usually difficult
to position and requires caution. However, antegrade stenting using this stent is
an appropriate indication of malignant biliary obstruction and can be successfully
performed without hesitation.
Fig. 2 Malignant hilar biliary obstruction by recurrence of cholangiocarcinoma as visualized
by computed tomography examination.
Fig. 3 Malignant hilar biliary obstruction by recurrence of cholangiocarcinoma as visualized
by endoscopic ultrasonography.
Antegrade stenting using a new covered multi-hole metal stent for malignant biliary
obstruction in surgically altered anatomy.Video 1
Endoscopy_UCTN_Code_TTT_1AS_2AD
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