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]).
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.
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.
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.
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.
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.
Endoscopy_UCTN_Code_CPL_1AK_2AC
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