Endoscopy
DOI: 10.1055/s-0043-117941
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Rescue antegrade diathermic dilation of hyperplastic tissue at partially covered metallic stent after EUS-guided hepaticogastrostomy

Hiroshi Kawakami1, 2, Yoshimasa Kubota1, 2, Tesshin Ban1, 2
  • 1Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
  • 2Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
Further Information

Corresponding author

Hiroshi Kawakami, MD, PhD
Department of Gastroenterology and Hepatology
Faculty of Medicine, University of Miyazaki
5200 Kihara, Kiyotake
Miyazaki, Miyazaki 889-1692
Japan   
Fax: +81-985-859802   

Publication History

Publication Date:
13 September 2017 (eFirst)

 

Endoscopic ultrasonography-guided antegrade stenting (EUS-AGS) and EUS-guided hepaticogastrostomy (EUS-HGS) are suitable for obstructive jaundice associated with gastric outlet obstruction or surgically altered anatomy [1]. Recently, a long partially covered self-expandable metallic stent (LPC-SEMS) has been developed to prevent stent migration and bile leakage and allow safe and effective EUS-HGS. However, one disadvantage of the LPC-SEMS is tissue hyperplasia at the uncovered portion of the stent [2]. Here, we present the case of a patient who underwent a rescue procedure using antegrade diathermic dilation for hyperplastic tissue occlusion of an LPC-SEMS and for tumor ingrowth into an uncovered SEMS placed for EUS-AGS.

A 60-year-old man with unresectable gastric cancer was admitted with gastric outlet obstruction and obstructive jaundice. He had undergone EUS-AGS using an uncovered metallic stent and EUS-HGS using a LPC-SEMS (diameter 6 mm, length 120 mm, uncovered proximal portion 10 mm; Taewoong Medical, Seoul, Korea). He again developed obstructive jaundice 7 months later. Antegrade cholangiography via the LPC-SEMS revealed perihilar bile duct stricture due to hyperplasia at the LPC-SEMS ([Fig. 1]). It was not possible to pass a tapered endoscopic retrograde cholangiopancreatography (ERCP) catheter through the stricture ([Video 1]). We successfully dilated the stricture using 6-Fr wire-guided diathermic dilation (Cysto-Gastro-Set; Endo-Flex, Voerde, Germany) ([Fig. 2, ] [Video 1]). Antegrade cholangiography showed free drainage through the previously hyperplastic area at the uncovered portion of the stent. No stent was placed as the previously occluded LPC-SEMS was now patent ([Fig. 3]). Subsequent antegrade cholangiography revealed occlusion of the uncovered metallic stent due to tumor ingrowth ([Fig. 4 a]). Passage was successfully obtained with antegrade diathermic dilation ([Fig. 4 b]). Finally, an ultraslim uncovered SEMS (BileRush Selective, 5.7-Fr, diameter 10 mm; Piolax Medical Devices, Kanagawa, Japan) was placed using a stent-in-stent method, without complications ([Fig. 5], [Video 1]).

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Fig. 1 Radiographic image from a 60-year-old man, showing perihilar bile duct stricture due to hyperplasia (arrows) at the long partially covered self-expandable metallic stent (LPC-SEMS), after endoscopic ultrasonography-guided hepaticogastrostomy 7 months earlier (inset: endoscopic image).

Video 1 Antegrade diathermic dilation and stenting technique to treat: (i) hyperplastic tissue occlusion of a long partially covered self-expanding metal stent (LPC-SEMS); and (ii) recurrent distal biliary obstruction by tumor ingrowth into an uncovered SEMS, following endoscopic ultrasonography-guided hepaticogastrostomy and antegrade stenting 7 months previously in a 60-year-old man.

Georg Thieme Verlag. Please enable Java Script to watch the video.
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Fig. 2 Radiographic image showing wire-guided antegrade diathermic dilation for hyperplastic tissue at the LPC-SEMS. a Before diathermic dilation; inset: endoscopic image. b After diathermic dilation.
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Fig. 3 Radiographic image showing free drainage through the previously hyperplastic area (arrows) at the uncovered portion of the LPC-SEMS after wire-guided antegrade diathermic dilation.
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Fig. 4 Radiographic images: a Tumor ingrowth in the uncovered self-expandable metallic stent in the distal bile duct, placed at endoscopic ultrasonography-guided antegrade procedure 7 months earlier. b Wire-guided antegrade diathermic dilation for the tumor ingrowth.
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Fig. 5 Radiographic image showing antegrade placement of ultraslim uncovered self-expandable metallic stent using the stent-in-stent method (inset: endoscopic image).

Recurrent biliary obstruction caused by tissue hyperplasia is an unresolved major problem of the LPC-SEMS, and the optimal rescue technique has not been established. EUS-guided antegrade diathermic dilation has been recently reported [3] [4] [5]. To our knowledge, this is the first report of rescue for hyperplastic tissue occlusion of an LPC-SEMS that used wire-guided antegrade diathermic dilation with no need for secondary stenting. This rescue technique is a useful method of recanalization of an LPC-SEMS occluded by hyperplastic tissue.

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Competing interests

Dr. Kawakami is a consultant to and gives lectures for Piolax Medical Devices, Kanagawa, Japan. The other authors declare no conflict of interests for this article.


Corresponding author

Hiroshi Kawakami, MD, PhD
Department of Gastroenterology and Hepatology
Faculty of Medicine, University of Miyazaki
5200 Kihara, Kiyotake
Miyazaki, Miyazaki 889-1692
Japan   
Fax: +81-985-859802   


Zoom Image
Fig. 1 Radiographic image from a 60-year-old man, showing perihilar bile duct stricture due to hyperplasia (arrows) at the long partially covered self-expandable metallic stent (LPC-SEMS), after endoscopic ultrasonography-guided hepaticogastrostomy 7 months earlier (inset: endoscopic image).
Zoom Image
Fig. 2 Radiographic image showing wire-guided antegrade diathermic dilation for hyperplastic tissue at the LPC-SEMS. a Before diathermic dilation; inset: endoscopic image. b After diathermic dilation.
Zoom Image
Fig. 3 Radiographic image showing free drainage through the previously hyperplastic area (arrows) at the uncovered portion of the LPC-SEMS after wire-guided antegrade diathermic dilation.
Zoom Image
Fig. 4 Radiographic images: a Tumor ingrowth in the uncovered self-expandable metallic stent in the distal bile duct, placed at endoscopic ultrasonography-guided antegrade procedure 7 months earlier. b Wire-guided antegrade diathermic dilation for the tumor ingrowth.
Zoom Image
Fig. 5 Radiographic image showing antegrade placement of ultraslim uncovered self-expandable metallic stent using the stent-in-stent method (inset: endoscopic image).