During endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) [1]
[2], the intrahepatic bile duct is small in diameter (usually 2 – 5 mm), with various
angles or curves between it and the common bile duct. If the guidewire is advanced
into a peripheral bile duct ([Fig. 1]), the guidewire must be retracted and advanced again. However, shearing of the guidewire
may occur when it is pulled into the fine-needle aspiration (FNA) needle ([Fig. 2]). If this adverse event arises, we use the “liver impaction technique.” First, the
guidewire is pushed adequately into the peripheral bile duct, and the FNA needle is
pulled back into the hepatic parenchyma ([Fig. 3]). Because the tip of the FNA needle is then within the hepatic parenchyma, shearing
becomes less likely ([Fig. 4]).
Fig. 1 A 79-year-old man was undergoing endoscopic ultrasound-guided hepaticogastrostomy
(EUS-HG). The guidewire (yellow dashed line) was accidentally advanced into a peripheral
bile duct and therefore needed to be retracted (red arrows) into the fine-needle aspiration
needle, before re-advancement into the hepatic hilar duct.
Fig. 2 When the guidewire (yellow dashed line) is pulled back, it may be sheared (red arrowheads)
by the tip of the needle.
Fig. 3 To prevent shearing of the guidewire (yellow dashed line), the aspiration needle
is pulled back (red arrows) into the hepatic parenchyma.
Fig. 4 Because the tip of the fine-needle aspiration (FNA) needle is within the hepatic
parenchyma, shearing between the guidewire and the FNA needle is now unlikely to occur.
A 79-year-old man was admitted to our hospital with obstructive jaundice due to advanced
pancreatic cancer with duodenal obstruction. First, the left intrahepatic bile duct
was punctured with a 19-gauge FNA needle. Contrast medium was injected. Although a
0.025-inch guidewire was inserted, it was accidentally introduced into a peripheral
bile duct. We retracted the guidewire to advance it into the common bile duct or hepatic
hilar duct. However, shearing of the guidewire occurred. After the guidewire had been
pushed into the peripheral bile duct, we carefully pulled the FNA needle into the
hepatic parenchyma with EUS imaging guidance. We were then easily able to pull the
guidewire back into the FNA needle. We then successfully re-advanced the guidewire,
into the bile duct in the hepatic hilum. After the FNA needle had been exchanged for
an endoscopic retrograde cholangiopancreatography (ERCP) catheter, contrast medium
was injected, and obstruction was seen in the lower bile duct. Finally, we performed
EUS-HG to completion ([Video 1]). No adverse events were associated with this procedure.
During endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG), the guidewire is
inadvertently introduced into a peripheral intrahepatic bile duct and then, upon retraction,
shears against the fine-needle aspiration (FNA) needle. Therefore, after pushing the
guidewire into the peripheral bile duct, we carefully pull the FNA needle back into
the hepatic parenchyma under EUS guidance. The guidewire is then easily retracted
into the FNA needle without shearing, and then successfully re-advanced into the bile
duct in the hepatic hilum. Finally, EUS-guided hepaticogastrostomy is completed.
Our technique may be useful to prevent guidewire shearing.
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