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CC BY 4.0 · Journal of Digestive Endoscopy
DOI: 10.1055/s-0045-1811571
Review Article

Technical Review on Endoscopic Ultrasound-Guided Hepaticogastrostomy

Vivek Kumar Singh
1   Department of Gastroenterology, Institute of Digestive and Liver Care, S.L. Raheja Hospital-A Fortis Associate, Mumbai, Maharashtra, India
,
Vinay Dhir
1   Department of Gastroenterology, Institute of Digestive and Liver Care, S.L. Raheja Hospital-A Fortis Associate, Mumbai, Maharashtra, India
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Abstract

Endoscopic ultrasound-guided biliary drainage (EUS BD) over the last decade has become accepted as a standard technique for BD in routine clinical practice. EUS-guided hepaticogastrostomy (HGS) has been adopted worldwide for various benign and malignant pathologies following failed endoscopic transpapillary cholangiopancreatography or inaccessible papilla due to duodenal stenosis or surgically altered anatomy. With increasing acceptance of EUS HGS, its efficacy and safety has now been tested for primary BD. Since its wider adoption, there is rising focus on improving EUS imaging and developing more dedicated accessories and stents, which cater to EUS HGS. With the aim of making the procedure safe and effective while reducing complication rates and making it more accessible, this review focuses on technical aspects of EUS HGS with tips and tricks that we use in our practice.


 

Keywords

endoscopic ultrasound - EUS-guided biliary drainage - EUS HGS

Background

Endoscopic ultrasound-guided hepaticogastrostomy (EUS HGS) since its first description in 2003 has evolved and is now considered as a reliable and safe technique for biliary drainage (BD) in patients with failed endoscopic transpapillary cholangiopancreatography (ERCP). Recent literature also supports use of EUS-guided BD as first-line palliation for malignant biliary obstruction with similar technical and clinical success rates and lower incidence of adverse events.[1] [2] Over the last two decades there has been a lot of evolution in the technique and the availability of dedicated devices for EUS HGS. In this review, we would like to focus upon the technical aspects of the procedure in a stepwise manner alongside reviewing the alternative techniques/methods and devices available for the same.


 

Step by Step Details of the Procedure/Technical Consideration

Step 1: Indication and Contraindications

A baseline cross-sectional imaging in the form of a computed tomography (CT) scan to arrive at the diagnosis and the extent of disease is a prerequisite. It is imperative to confirm the diagnosis histopathologically, using endoscopic/CT/EUS-guided biopsy whenever feasible. Before attempting EUS HGS it is advisable to have a magnetic resonance cholangiopancreatography to know the ductal configuration, level of obstruction, confirm adequate dilatation of the intrahepatic biliary radical (IHBR), presence of intervening blood vessel or lesion, ascites, and left lobe atrophy.

In our practice, ERCP remains the first line of therapy in patients with malignant biliary obstruction for both distal and hilar blocks. EUS HGS is considered as a rescue therapy in patients where ERCP fails. Other indications include situations where ERCP is not feasible like gastric outlet obstruction due to distal lumen compromising gastric cancers and duodenal stenosis where scope could not be passed up to D2 or surgically altered anatomy where D2 is not accessible. EUS HGS may be used in patients with distal block and type I hilar blocks, where stenting the left hepatic system drains both the left and the right lobe of liver since the communication between the left and right biliary system is preserved. In type II block a bridging technique can be used to drain both the right and left systems. Whereas in type III and IV blocks, where the right and left systems are noncommunicating, but the right biliary system can be accessed and drained via the transpapillary route, EUS HGS can be used for draining the left biliary system. EUS HGS also is used in patients with progressive hilar blocks where patient already has self-expanding metal stent (SEMS) in the common bile duct (CBD) and now presents with cutoff of left hepatic duct and repeat ERCP attempts fail at accessing the left biliary system. Appropriate patient selection remains the cornerstone to achieve good clinical outcomes.

Contraindications: Absolute contraindications include coagulopathy (international normalized ratio > 1.5), severe thrombocytopenia (< 50,000/µL), and hemodynamically unstable patient.

Relative contraindications include:

  • (1) Ascites

  • (2) Lack of suitable dilated IHBR (< 4–5 mm)

  • (3) Atrophic left lobe of liver

  • (4) Left portal vein thrombosis

  • (5) Portal hypertension with perigastric collaterals or gastric varices

  • (6) Intervening parenchymal lesion or major blood vessel (left hepatic vein)

Large volume ascites increases the distance between gastric puncture site and liver. This increases the chances of intraprocedure peritoneal bile leak, peritonitis, and stent migration into the peritoneum during stent deployment. A study evaluating the use of continuous ascitic fluid drainage to overcome this limitation showed promising results.[3]

Endoscopic drainage of left IHBR should be avoided in presence of atrophic left lobe of liver. This left lobe atrophy/dysfunction could be part of a long-standing biliary obstruction, compromised vascular supply, or metastatic infiltration of the left lobe of liver. Since there is no functional liver parenchyma left, draining the left lobe might not lead to meaningful improvement in the liver function. It is also associated with higher risk of bile leak, cholangitis, and stent dysfunction.[4] [5]

Left portal vein thrombosis is associated with poor visualization of small vessels with collateral formation, which increase the chances of unintentional vascular injury and excessive bleeding during puncture with needle, tract dilatation, or while stent placement. Also, it leads to compromised vascular supply to the left lobe and resultant atrophy of the left lobe of liver.

Intervening collaterals: Parenchymal lesions along the anticipated needle tract or poor EUS window where the left hepatic vein could not be avoided during puncture remains major contraindications in view of higher adverse events and should be avoided.


 

Step 2: Biliary Radical Identification and Puncture Site Selection

Identify dilated IHBD [segments II (B2)/III (B3)] in the left lobe of liver using linear EUS from the gastric cardia or body.

If technically feasible a segment III radical, upstream from the junction of segment II to III confluence and at least > 2 cm from the hepatic hilum to avoid major vasculature should be selected using the longest axis approach (to avoid shearing), which allows for more coaxial guidewire advancement and easier manipulation of accessories.

Characteristics to be looked for before puncturing the duct using a fine-needle aspiration (FNA) needle includes: adequately dilated segmental radical preferably > 4 to 5 mm, an intervening liver parenchyma of approximately 2 to 3 cm.[6]

To puncture the segment III radical, the scope is pushed down into the gastric cardia with an upward angulation toward the hilum. A stable scope position with slight angulation toward the hilum on fluoroscopy and confirming that the puncture site is below the diaphragm, thus avoiding esophageal puncture ([Fig. 1B]). A thorough Doppler interrogation along the entire planned needle path between the gastric wall and the target duct to avoid significant vessels before accessing the duct ([Fig. 1A]).

Zoom
Fig. 1 Identification and puncturing of segment 3 radical, followed by guidewire passage and tract dilatation and wire exchange. (A) Identification of segment 3 radical on endoscopic ultrasound (EUS) under Doppler guidance. (B) Curved scope position on fluoroscopy pointing toward the hilum. (C) Puncture of segment 3 radical using 19G needle. (D) Contrast injection and delineation of ductal anatomy. (E) Passing Terumo guidewire (0.025 inch) through the needle. (F) Passage of cystotome followed by exchange of Terumo wire with Visiglide wire.

Avoiding Transesophageal Puncture

Endoscopically being at least 2 to 3 cm below the squamocolumnar junction (in the absence of hiatus hernia).

In patients with hiatus hernia EUS confirmation by identification of right crus of diaphragm.

Fluoroscopically, identifying the diaphragm and keeping the tip of the EUS scope below the diaphragm. Alternatively, a clip can be applied to identify the gastroesophageal junction.


 

Selection of B2 versus B3 Radical

Segment II (B2): Is located more proximally and is straighter in course with a neutral scope position making passing of guidewire into the duct easier. Since the puncture is made more proximally, it is associated with higher chances of transesophageal puncture and mediastinitis.

Segment III (B3): Located more distally and difficult to access requiring slight angulation of the scope toward the hilum as compared with a straight scope position for B3 radical puncture. Requires more guidewire manipulation since the direction of the needle and expected guidewire trajectory has acute angulation. EUS HGS can be performed through both B2 and B3 radicals, provided the needle puncture is below the diaphragm.


 

 

Step 3: Puncturing the Biliary Radical

We use a 19-gauge FNA needle (standard for wire passage capability). In rare cases with minimally dilated radicals, a 22G needle may be used initially followed by saline injection to distend the biliary radicals. Before puncturing withdraw the stylet and prime the needle with saline. This avoids air bubbles entering the IHBR, which creates artifacts on EUS images. Advance the needle under real-time EUS guidance along the prescanned, vessel-free path ([Fig. 1C]). Do not exert excess pressure on the transducer as it can compress vessels and dampen the Doppler flow.

Once sure about the target duct and clear of any intervening vessels and ducts, a swift puncture into the duct should be attempted. Once the duct wall is punctured, aspirate bile before contrast injection to confirm intraductal position. Occasionally, counter-puncture of the opposite wall ensures, in this scenario gentle withdrawal with continuous suction can be attempted (withdrawal technique). While withdrawing aspiration of the bile in the syringe confirms intraductal position. An obtuse angle between the scope and the needle increases the success rate of guidewire insertion.


 

Step 4: Bile Aspiration and Contrast Injection

Aspirate bile to decompress the duct. This step helps in confirmation of the intraductal position of the needle, reduces chances of bacterial dissemination in patients with ongoing cholangitis, and reduces the chances of bile leak during subsequent steps.

Inject a small volume of diluted iodinated contrast (1:1 or 1:2 with saline) under live fluoroscopy to confirm opacification of the target duct and identify level of obstruction ([Fig. 1D]). As a rule, injecting in small volume of 1 to 2 mL and stopping as soon as sufficient delineation has been achieved. While injecting contrast make sure to avoid overdistension to minimize risk of bacteremia/sepsis and bile leak during accessory change. Also, overzealous contrast injection may interfere with visualization of the guidewire and hamper guidewire manipulation. Once duct anatomy is delineated, flushing the contrast out of EUS needle using 1 to 2 mL of saline, improves guidewire manipulation. Once the target radical is punctured satisfactorily, it is important to keep in echoendoscope in a stable position. An assistant may be needed for this.


 

Step 5: Guidewire Manipulation

Guidewire introduction through the needle into the biliary tree is a critical and technically challenging step. In our practice, we start with a short, angled tip hydrophilic guidewire (0.025 inch, 250 cm) (Radifocus; Terumo, Tokyo, Japan). Alternatively, a 0.025 stiff guidewire with a floppy tip (VisiGlide, Olympus, Tokyo, Japan) may also be used. We do not use 0.035 inch despite being compatible with 19G needle, because a smaller diameter wire improves maneuverability and reduces chances of shearing. The scope tip should be facing toward the hilum and the needle tip directed toward central IHBR to avoid entry of wire into peripheral ducts.

Once within the duct, gradually advance the tip of the wire through the needle deep into the IHBR, ideally across the hilum into the common hepatic duct (CHD) or contralateral system. Once the wire reaches across the hilum into the right hepatic system or CHD, the tip of the wire is coiled to form a loop, which provides stability during exchange of accessories (∼10–20 cm length of guidewire is passed under fluoroscopy guidance) ([Fig. 1E]). In cases where passing the guidewire beyond the hilum is not possible, we can coil the guidewire in the left intrahepatic duct by forming 1 to 2 loops.

Practical tips for guidewire manipulation:

  • Attempt should be made to maintain an obtuse angle between the needle and the wire, which is known to prevent shearing of the guidewire. Forward movement of the guidewire should be slow and always under continuous fluoroscopy guidance.

  • Loop formation technique, where the tip of the wire is coiled into a loop while navigating through the IHBR prevents trauma to the duct wall/penetration into the parenchyma.

  • Despite the efforts to direct the guidewire toward central IHBR, occasionally the wire travels to the peripheral ducts. In such situation gently pulling the wire back with slight rotating movement using the index finger and the thumb and redirecting it toward the central ducts helps. Occasionally, while retracting the wire back a sensation of “catching,” which is a sudden abnormal resistance, may be felt. In such situation instead of pulling the wire back with excessive force, which can lead to shearing, the guidewire should be gently pushed in followed by gentle withdrawal using back and forth movement with slight rotation.

  • If the guidewire travels too far into the peripheral duct the risk of wire shearing increases significantly. In such scenario, “liver impaction”[7] technique can be used. In this we try to pull the needle back few millimeters into the hepatic parenchyma under EUS view, which makes the angle between the wire and needle obtuse and decreases the chances of shearing and improves the chances of guidewire passage in the desired duct.[8] If the above techniques fail, withdrawing the needle along with the wire and taking a new puncture with more favorable angle on fluoroscopy should be attempted.

  • Some authors recommend using a hydrophilic 0.035-inch guidewire without coating to reduce the chance of wire shearing,[9] while a stiff 0.025-inch guidewire is preferred by many for the ease of accessory exchange over a stiff wire.[10]


 

Step 6: Track Dilation

Carefully withdraw the needle under EUS and fluoroscopy guidance till we run out of wire (short wire exchange). At this point, connecting a 10-mL syringe filled with normal saline at the connector and injecting under pressure while simultaneously withdrawing the needle under fluoroscopy guidance. In case of long wire direct removal of the needle over the guidewire can be done.

After needle removal, even slight manipulation of the scope may cause the guidewire exit point from the puncture site to become misaligned with the endoscope tip, potentially resulting in looping of instruments inside the gastric lumen when negotiating the puncture site over the guidewire. To prevent this, we try and maintain the guidewire under EUS view throughout (from removing the needle to reinserting the accessories). Over the guidewire tract dilation devices can be passed.

Dilating the tract includes dilatation of the stomach wall, peritoneum, liver capsule, intervening hepatic parenchyma, and finally the duct wall. In our practice, we prefer coaxial electrocautery-based dilation using a 6Fr cystotome (G-Flex, Belgium). Apply controlled pure-cut current under fluoroscopic and EUS guidance while advancing through the gastric wall and liver parenchyma. Once into the duct, a sense of give-way is felt beyond which the cystotome is passed without any resistance over the guidewire. Avoid excessive force while going across the gastric wall and liver parenchyma as it may lead to looping of cystotome in the stomach. We prefer to pass the cystotome beyond the hilum into the CHD or right biliary system.

Alternatively, mechanical dilators like graded dilatation catheters (starting with 4Fr and gradually progressing to 6 or 7Fr) or balloon dilators (4 and 6 mm) can be used. In current practice, noncoaxial cautery type dilator (needle knife) are rarely used and are replaced by coaxial electrocautery dilator.[11]

The goal of this step is to create a fistula tract large enough for stent delivery (typically 6–8Fr diameter).


 

Step 7: Guidewire Exchange

After dilation, the initial hydrophilic short wire is exchanged for a stiffer wire to facilitate for stent delivery. Advance a stiffer guidewire (0.025-inch guidewire, VisiGlide, Olympus Medical) deep into the biliary tree through the cystotome. Ensure the stiff wire has a stable position deep within the ducts ([Fig. 1F]). Once the stiff wire is in place, cystotome can be gradually removed. Upon removal of the dilating instrument, some amount of bile leak is common and can be seen on EUS as well as fluoroscopy as contrast leak. To minimize this leak, subsequent loading of the stent over the guidewire should be quick. Having stent ready at this stage reduces the delay and the amount of bile leak. Guidewire exchange is not necessary if a long stiff guidewire was used initially.


 

Step 8: Stent Insertion

An ideal HGS stent should have antimigration property with anchoring ability at either ends, which will serve as an anchor between hepatic duct and gastric lumen with a covered intervening portion to avoid bile leak, that is, the part between liver surface and gastric wall.

Plastic stent: In the early days of HGS, plastic stents were used but due to smaller draining diameters risk of early stent block was a concern. Since plastic stent do not expand and oppose the hepatic parenchyma and the gastric wall firmly, chances of bile leak is deemed to be higher. Still dedicated plastic stents can have a role, especially in patients with benign stricture where frequent stent exchange is required.

Covered SEMS (cSEMS): Use of 6 and 8 cm cSEMS, 6 and 8 mm in diameter have been described in literature. Due to its larger diameter and expandable nature chances of early block and bile leaks and overall adverse event rates (AER)s are less as compared with plastic stent.[12] Since these stents are fully covered and have no antimigration property, chances of migration of the gastric end into the peritoneum leading to biliary peritonitis remains a concern. To reduce this SEMS with antimigration property at the gastric end and leaving > 3 cm length of the stent in the stomach has been adopted by experts to reduce early and delayed migration risk.[13] Also, the covered intraductal portion of the SEMS can lead to block of segmental radicals and if not drained can lead to segmental cholangitis and abscess formation. In view of the above issues, use of cSEMS has taken a backseat with current literature supporting the use of partially covered long stents with antimigration property.

The most common HGS stent in our practice is Niti-S GIOBOR stent (Taewoong Medical). Other SEMS with similar property like partially covered, braided with antimigration property include HANARO stent BPD (M.I. Tech), Hybrid BONA stent (Standard Sci. Tech), DEUS (Standard Sci. Tech), and Niti-S Spring stopper stent (Taewoong Medical). Niti-S GIOBOR stent is available in 10 and 8 cm length with diameter of 8 and 10 mm. It is 70% covered at the gastric end and 30% length is uncovered toward hepatic ducts and it has antimigration flare at the gastric end. The delivery system is 8.5Fr in profile and can be passed after dilatation with a 6Fr cystotome.

Stent delivery system is loaded over the guidewire through the EUS scope. Advancing the delivery system under fluoroscopic guidance through the dilated tract until the distal end (marker) reaches up to the hilum and is well within the bile duct (typically 2–3 cm intraductal length). At this stage due to the force of pushing the stent introducer system deep into the bile duct the scope tip may be pushed back and increases the distance between the scope tip and gastric wall, which increase the chances of stent getting deployed into the abdominal cavity. At this stage we start to pull back the stent introducer system with an objective to keep only the uncovered portion of the stent in the bile duct (marker on the stent is used to identify the junction of covered and uncovered portion of the stent). This pulling back also reduces the scope tip distance from the stomach. Once confident about the stent introducer position on fluoroscopy, stent deployment can be initiated ([Fig. 2]).

Zoom
Fig. 2 Stent deployment. (A) Niti-S GIOBOR stent passed over the guidewire up to the hilum. (B) Deployment of uncovered portion of the stent under fluoroscopy guidance. (C) Stent deployed up to scope tip followed by further intrachannel deployment of the rest of the stent. (D and E) Moving the scope tip away from the gastric wall followed by pushing of the stent introducer to see deployment of the stent under direct endoscopy guidance. (F) Completely deployed stent with long intragastric segment.

 

Step 9: Stent Deployment

After positioning the introducer, the assistant starts deploying the stent under fluoroscopy guidance while simultaneously the physician maintains a counter-traction on the introducer with an objective to maintain the stent tip position constant. Once the uncovered part of the SEMS is deployed (marked by a radio-opaque marker on the stent) within the biliary radical, further traction by the endosonographer reduces the distance between the liver and the stomach. However, it is important not to apply too much traction as the stent may suddenly be released within the liver. We continue to deploy the stent under fluoroscopy guidance till the distal marker reaches the scope tip, then the rest of the SEMS is deployed inside the scope (intrachannel release method). At this point, the physician starts to push the introducer inwards so that the expanded portion of the deployed SEMS starts emerging from the scope tip. This inward push creates a gap between the scope and the gastric wall where the opened SEMS can be visualized directly on endoscopy view. Beyond this, the push movement of the assistant and the pull action of the physician continues while gradually moving the scope tip away from the gastric wall using down wheel and slowly withdrawing the scope, eventually releasing the entire gastric end of the stent in the stomach lumen. Free flow of the bile into the stomach can be seen after complete deployment. At least 3 to 5 cm of the stent should be within the stomach, which has been shown to decrease the chances of peritoneal migration of the stent ([Fig. 2]).


 

Step 10: Use of Plastic Stent

In general, SEMS are used for EUS HGS in malignant diseases, but the use SEMS in benign disease is still questionable. For the same reason, specially designed plastic stent which can undergo frequent exchanges have been devised for benign pathologies with inaccessible papilla. Two such stents which have been used in practice include:

A dedicated 7Fr 20 cm single pigtail plastic stent (effective length of 15 cm) for interventional EUS, with a tapered tip for improved penetration and four flanges to prevent migration. The middle portion of the stent has no holes to prevent bile leaks (Through and Pass, TYPE-IT, Gadelius Medical Co. Ltd., Tokyo, Japan).[14] In Japan, the 8-Fr push-type stent, 7-Fr push-type stent, and 7-Fr modified consolidated repositionable-type stent are available for commercial use.

A more recent, novel spiral plastic stent[15] has shown safety and efficacy in terms of removability. Most plastic stents have flaps to prevent stent migration/dislocation. But, unlike the CBD the IHBR have side branches where the flaps may get stuck leading to risk of rupture. To overcome this spiral plastic stent has no side flaps, which prevents the stent from getting stuck at the time of removal but also address the issue of stent migration by having a distal spiral shape and a pigtail at the proximal end with no holes in the intervening part to avoid bile leak.

Deployment of plastic stent is done over the already placed stiff guidewire under fluoroscopy guidance. Once the stent reaches intrahepatic duct, using the down-knob creates a space between the gastric wall and the scope tip and under endoscopic view deploy the pigtail of the stent once the proximal marker on the stent is seen.


 

 

Few Key Considerations Throughout

  • Role of antibiotics: Prophylactic antibiotics is mandatory (e.g., intravenous ciprofloxacin or third-generation cephalosporin). In cases with suspicion of cholangitis, bile aspirated after puncturing the bile duct should be send for culture and sensitivity.

  • Team coordination: Successful EUS HGS relies not only on the expertise of the endoscopist but also on the collaboration of an assistant well-versed in biliary anatomy and proficient in guidewire negotiation, ensuring precise and safe instrumentation. Interventional radiologist and hepatobiliary surgeons should be available in the hospital in the event of a complication.

  • Complication surveillance: Continuous monitoring for intraprocedure complications like bleeding, perforation, bile leak, and stent misdeployment/migration throughout the procedure.

  • Postprocedure: We keep all our patients nil per orally and on continuous intravenous fluids till next day morning. Monitor for signs of complications like fever, abdomen pain, vomiting, and hemodynamic compromise. Consider abdominal X-ray/ultrasound of the abdomen next day to confirm stent position, if required.


 

Conclusion

EUS HGS is an effective and safe option for BD in malignant obstruction when ERCP fails or is not feasible. This review focuses on the technical aspects of the procedure, so as to simplify the procedure and make is more safe and successful.

Role of other modalities of BD like EUS-guided choledochoduodenostomy and EUS guided antegrade stenting as compared with EUS HGS still requires further evaluation with prospective studies. Despite the evolving EUS technology and availability of newer stents and accessories for EUS HGS, the procedure still remains technically demanding with not so rare AERs. Further improvement in the operators' training in terms of technical skills with well-structured training program and further research into dedicated EUS HGS accessories will not only help in faster and wider adaptation of the technique but also improve the technical and clinical success related to the procedure.


 

 

Conflict of Interest

None declared.


Address for correspondence

Vivek Kumar Singh, DrNB
Institute of Digestive and Liver Care, S.L. Raheja Hospital-A Fortis Associate
Mumbai 400016, Maharashtra
India   

Publication History

Article published online:
11 September 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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Zoom
Fig. 1 Identification and puncturing of segment 3 radical, followed by guidewire passage and tract dilatation and wire exchange. (A) Identification of segment 3 radical on endoscopic ultrasound (EUS) under Doppler guidance. (B) Curved scope position on fluoroscopy pointing toward the hilum. (C) Puncture of segment 3 radical using 19G needle. (D) Contrast injection and delineation of ductal anatomy. (E) Passing Terumo guidewire (0.025 inch) through the needle. (F) Passage of cystotome followed by exchange of Terumo wire with Visiglide wire.
Zoom
Fig. 2 Stent deployment. (A) Niti-S GIOBOR stent passed over the guidewire up to the hilum. (B) Deployment of uncovered portion of the stent under fluoroscopy guidance. (C) Stent deployed up to scope tip followed by further intrachannel deployment of the rest of the stent. (D and E) Moving the scope tip away from the gastric wall followed by pushing of the stent introducer to see deployment of the stent under direct endoscopy guidance. (F) Completely deployed stent with long intragastric segment.