Biliary stones extraction through hepatico-gastrostomy in surgically altered anatomy or non-accessible papilla : a multicenter retrospective French study

Aims Endoscopic Retrograde Cholangiopancreatography (ERCP), the standard endoscopic procedure for biliary stone extraction, can be challenging in patients with duodenal stenosis or surgically altered anatomy (SAA). Initially recommended for malignant bile duct obstruction, EUS-guided Hepaticogastrostomy (EUS-HGS) is increasingly applied in benign biliary diseases. This study evaluates the success rate and complications associated with stone extraction through a 'benign' HGS.

Methods This retrospective multicenter study included patients with SAA or benign duodenal stenosis who presented for biliary stones and underwent EUS-HGS for stone extraction. Patients with malignant diseases or those who had EUS-assisted rendezvous procedures were excluded. The primary endpoint was the successful bile duct clearance through the HGS. Secondary endpoints included the technical success of HGS, complication rates, and stone recurrence rate during follow-up.

Results Thirty-four patients, with a median age of 72 years [66-80], were included in 6 endoscopic expert centers, between 2015 and 2024. 32 patients had SAA, and two others had benign duodenal stenosis. Among patients with SAA, 41% (n=13) had preserved papilla and 62% (n=20) had an associated bilioenteric anastomotic stricture. The median follow-up duration was 8 months (1-17). Large stones (> 10 mm) were present in 68% of patients. One-third of patients had multiple stones (> 5 stones). Enteroscopy-assisted ERCP and PTBD had failed in 24% (n=8) and 3% (n=1) of patients respectively, before attempting the EUS-HGS. Successful stone extraction through an HGS was achieved in 88% of patients (n=30). Three technical failures (8.8%) of HGS were noted, including two failures to puncture thin bile ducts and one immediate perprocedural migration of the covered metallic stent. Following the technical success of HGS, stone extraction succeeded in 91% of patients (n=30). Cholangioscopy-assisted electrohydraulic lithotripsy (EHL) could be successfully performed when needed in 94% of patients (15 over 16 patients) to achieve stone extraction. The HGS procedure complication rate was 38% (n=14), with 57% (n=8) of these complications being moderate to severe. Most complications were managed conservatively or endoscopically in 79% of cases. No mortality related to the endoscopic interventions was noted. Stone recurrence occurred in 20% of patients after a median duration of 9.5 months [6-12] following complete stone extraction. Recurrence was managed successfully in 66% of cases (n=4) via HGS and by cholangioscopy-assisted EHL in 33% of cases (n=2).

Conclusions Hepaticogastrostomy (HGS) is an effective option for treating biliary stones in patients with SAA. It enables cholangioscopy-assisted EHL for large stones, thus broadening therapeutic options for complex biliary stones. However, it remains an 'expert' endoscopic procedure that awaits further standardization and carries a notable risk of complications, most of which can be managed endoscopically or conservatively.

Conflicts of Interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
27 March 2025