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Narrated case of an EUS-guided hepaticogastrostomy facilitated by opacification and distention of the left intrahepatic ducts using an existing percutaneous drain tract.
Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage.
In the absence of biliary dilation, the procedure can be technically challenging because access to the biliary tree is commonly obtained transgastrically with EUS-guided puncture of the left intrahepatic ducts. Here, we present the use of a preexisting percutaneous transhepatic biliary drain (PTBD) tract to distend the left-sided biliary tree and facilitate the completion of EUS-HG (Video 1, available online at www.giejournal.org).
Case
A 43-year-old woman with a history of total pancreatectomy for chronic pancreatitis followed by surgical revision, which included a Roux-en-Y reconstruction and hepaticojejunostomy (HJ), presented for a second opinion regarding recurrent episodes of cholangitis despite a relatively patent HJ. There was significant concern for biliary limb dysmotility, and she initially underwent surgical revision of the jejunojejunostomy with limited improvement. She continued to have issues with cholangitis, prompting placement of a PTBD. Cholangiography through the drain confirmed diffuse, intrahepatic stricturing (Fig. 1, arrow) and a patent HG (Fig. 1, arrowhead). Her course was subsequently complicated by high biliary drain output, which exceeded 1 to 2 L per day. This resulted in frequent hospitalizations for dehydration as well as progressive fat-soluble vitamin deficiency despite aggressive supplementation. After a multidisciplinary discussion involving surgery, interventional radiology, and gastroenterology, it was felt that internalizing drainage would help address these issues by promoting a more physiologic flow of bile.
Figure 1Cholangiogram obtained through a percutaneous transhepatic biliary drain highlighting diffuse intrahepatic strictures (arrow), a relatively patent hepaticojejunostomy, and contrast pooling in the biliary limb.
The procedure was performed with the patient under general anesthesia, and the patient was given a dose of peri-operative piperacillin-tazobactam. The PTBD was first exchanged over a wire to a sheath and balloon catheter. Under fluoroscopic guidance, the percutaneous balloon catheter was advanced into the left hepatic duct, the balloon inflated (Fig. 2, arrow), and contrast injected to opacify and distend the target ducts (Fig. 2). A branch of the left hepatic duct was then punctured under EUS-guidance with a 19-gauge needle followed by advancement of a 0.025-inch angled guidewire across the HJ. After dilating the tract with a 4-mm balloon, a 10-mm × 8-cm fully covered self-expandable metal stent was deployed with the distal end in the left hepatic duct and proximal end in the stomach (Fig. 3, arrow). A guidewire was then used to access the right hepatic duct, and a plastic double-pigtail catheter was deployed across the HG (Fig. 3, arrowhead). The patient did well postprocedurally with no additional hospitalizations for cholangitis and improvement in nutrition parameters.
Figure 2A balloon occlusion catheter passed through the existing percutaneous drain tract with the balloon insufflated (arrow) and contrast injected to opacify and distend the left intrahepatic duct.
Figure 3Final fluoroscopic imaging showing the fully covered metal stent traversing the hepaticogastrostomy (arrow) and plastic double pigtail stent draining the right side of the biliary tree (arrowhead).
Routine stent exchange was performed at 8 weeks, at which time all stents were removed and exchanged for plastic stents, including 3 traversing the HJ (Fig. 4, arrow) and 1 in the right posterior hepatic duct (Fig. 4, arrowhead). The metal stent was replaced with plastic stents as destination therapy to minimize any risk of erosion, migration, and bleeding. It is our experience that the plastic stents help with tissue apposition and formation of the hepaticogastrostomy while minimizing mucosal injury when the gastric lumen collapses. These stents would likely need to be exchanged every 6 to 12 months indefinitely to prevent cholangitis, which is a limitation to this approach, but was discussed with the patient and felt to be much more advantageous than repeated hospitalizations. It also allowed for physiologic bile flow and improved nutrient absorption. Multiple stents were used given the size of the ducts and to maintain patency for extended periods of time. In theory, multiple stents also provide for continued drainage if one stent were to become occluded. The patient did well postprocedurally with no additional hospitalizations for cholangitis and improvement in nutrition parameters. She continues to follow up with local providers for routine stent exchanges.
Figure 4Routine stent exchange performed at 8 weeks with removal of initial stents and placement of 4 pigtails, 3 traversing the hepaticojejunostomy (arrow) and one in the right posterior hepatic duct (arrowhead).
Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach.
Visualization of the intrahepatic ducts is critical, and the procedure can be technically demanding in patients without dilated ducts. Here we report a creative approach to the procedure, which unencumbered the patient from external hardware and improved her nutrition through internalizing biliary drainage. The case also highlights the importance of careful patient selection and using a multidisciplinary, collaborative approach to maximize the likelihood of a successful outcome.
Disclosure
Dr Law is a consultant for ConMed and Boston Scientific and receives royalties from UpToDate. All other authors disclosed no financial relationships.
Narrated case of an EUS-guided hepaticogastrostomy facilitated by opacification and distention of the left intrahepatic ducts using an existing percutaneous drain tract.
References
Liao W.C.
Angsuwatcharakon P.
Isayama H.
et al.
International consensus recommendations for difficult biliary access.
Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage.
Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach.
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