Assessing postoperative retroperitoneal malignant invasion with duodenal stenosis
and obstructive jaundice is challenging. After surgical reconstruction, endoscopic
access through the retroperitoneum becomes difficult, complicating efforts to improve
these conditions. Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS)
is a highly effective treatment for obstructive jaundice [1]. However, deploying several devices through the needle tract remains considerably
challenging.
This video presents a 61-year-old Japanese man who had undergone distal gastrectomy
and Roux-en-Y reconstruction for gastric cancer 4 years prior. Imaging indicated recurrence
of gastric cancer, inducing obstructive jaundice with retroperitoneal invasion. Thus,
histological diagnosis and biliary drainage were planned using the EUS-HGS procedure
([Fig. 1]).
Fig. 1 Abdominal imaging. a Computed tomography images showed
retroperitoneal thickness with duodenal stenosis and obstructive bile duct stenosis.
White
stars (*) indicate gastric cancer recurrence. b, c Endoscopic
(b) and fluoroscopic (c) images showed
that single-balloon enteroscopy could not access the papilla of Vater because of gastric
cancer recurrence with retroperitoneal invasion.
EUS-HGS was performed using a convex echoendoscope (GF-UCT260; Olympus Medical Systems,
Tokyo, Japan). The bile duct (segment B2) was punctured under EUS guidance using a
19-gauge needle (Ez-shot 3 Plus; Olympus Medical Systems). A 0.025-inch guidewire
was inserted, followed by mechanical dilation of the needle tract using a catheter
and bile juice aspiration. A guide sheath with a tapered tip (EndoSheather; Piolax
Inc., Yokohama, Japan) was inserted over the guidewire. The inner catheter was removed,
and the outer sheath remained inside the common bile duct. Biopsies of the duodenal
mucosa were performed using biopsy forceps 1.8-mm in diameter (Radial Jaw 4P; Boston
Scientific, Marlborough, Massachusetts, USA). Finally, a 5.9-Fr fully covered self-expandable
metal stent (6 mm × 12 cm HANAROSTENT; Boston Scientific) was placed. The biopsy confirmed
gastric cancer recurrence ([Fig. 2], [Fig. 3], [Video 1]).
Fig. 2 The endoscopic tapered sheath (EndoSheather; Piolax Inc., Yokohama, Japan). a Minimal caliber difference exists between inner and outer catheters at the device
tip. b The gap between the sheath and guidewire is minimized, allowing for smooth insertion
of the device into the puncture site. c The outer sheath with a mesh-braided structure provides optimal kink resistance.
d The inner catheter is removed, and the outer sheath remains inside the common bile
duct. Biopsy forceps with 1.8-mm diameter (Radial Jaw 4P; Boston Scientific, Marlborough,
Massachusetts, USA) is inserted into the outer sheath of the device delivery system.
e A combination of pushing and pulling the biopsy forceps and opening and closing the
tip are performed to guide the forceps toward the target site (white arrow).
Fig. 3 The endoscopic ultrasound-guided hepaticogastrostomy procedure (EUS-HGS) with histological
diagnosis and biliary drainage. a EUS-HGS was performed using a convex echoendoscope (GF-UCT260; Olympus Medical Systems,
Tokyo, Japan). The bile duct (segment B2) was punctured under EUS guidance using a
19-gauge needle (Ez-shot 3 plus; Olympus Medical Systems). b A 0.025-inch guidewire was inserted, followed by mechanical dilation of the needle
tract using a catheter and bile juice aspiration. A guide sheath with a tapered tip
(EndoSheather; Piolax Inc., Yokohama, Japan) was inserted over the guidewire. c The inner catheter was removed, and the outer sheath remained inside the common bile
duct. d Biopsies of the duodenal mucosa were performed using biopsy forceps with 1.8-mm diameter
(Radial Jaw 4P; Boston Scientific, Marlborough, Massachusetts, USA). e Finally, a 5.9-Fr fully covered self-expandable metal stent (6 mm × 12 cm; HANAROSTENT,
Boston Scientific) was placed.
Initial experience with duodenal biopsy and drainage procedures via the hepaticogastrostomy
route using a newly designed device delivery system.Video 1
This video demonstrates a biopsy technique using a novel endoscopic sheath via the
EUS-HGS route [2]
[3]. This device functions as a dilation tool and delivery system, enabling mechanical
dilation of the needle tract while facilitating the smooth insertion of biopsy forceps
through the indwelling outer sheath. The sheath effectively bridges the gap at the
target site, minimizing the risk of bile leakage. Consequently, EUS-HGS can be performed
promptly.
Endoscopy_UCTN_Code_TTT_1AS_2AH
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
