Vishal Ghevariya, MD from the Icahn School of Medicine at Mount Sinai in New York shares this video case titled “EUS-guided hepatogastrostomy with double stenting.”
Minimally invasive biliary drainage techniques have recently gained popularity among interventional endoscopy services. We present the technique of hepatogastrostomy creation for malignant biliary obstruction in a 54-year-old man with biliary stricture from unresectable cholangiocarcinoma.
The patient initially presented to an outside hospital with severe right upper quadrant pain, 40-lbs weight loss, and deep jaundice. ERCP failed to achieve biliary access. Percutaneous drainage was performed. Unfortunately, brushings from percutaneous access were negative for malignancy and the drainage catheter dislodged twice. His CA 19-9 was 214511 (0-37 U/mL).
Upon arrival at our institution, the patient demonstrated WHO performance score of 3 and intense fear of percutaneous drainage due to previous dislodgement of the catheter. Review of CT and MRCP was suggestive of Bismuth type II stricture. The gallbladder appeared inflamed and distended suggestive of cystic duct occlusion from this malignant process. EUS with FNA from periceliac lymph node confirmed diagnosis of adenocarcinoma. He was deemed unresectable.
Figure 1. Abdominal radiograph demonstrates hepatogastrostomy along with transpapillary biliary stent and dislodged percutaneous catheter
ERCP was repeated and was successful. Cholangiogram revealed a stricture involving common hepatic duct and severely dilated intrahepatic biliary radicals within segments 5-8. The left intrahepatics (segments 2-4) were not visualized. An uncovered metal biliary stent was placed to provide drainage to opacified right-sided liver segments. Transpapillary drainage with uncovered stent would likely provide some gallbladder drainage as well.
There was no evidence of liver atrophy or ascites on CT scan. Bilateral drainage was pursued given very high bilirubin (total bilirubin-29.4 (0.3-1.0 mg/dL). Using a linear echoendoscope and access needle, a dilated intrahepatic biliary radicle within segment 3 of the liver was accessed. Transgastric cholangiogram failed to demonstrate communication of segments 2-4 with other liver segments or common duct. Gastric access site was enlarged using a needle knife and blended current and a partially covered metal stent was placed to create a hepatogastrostomy. A double pigtail stent was inserted within the metal stent to minimize the risk of migration of the metal stent.
The patient reported resolution of right upper quadrant pain within 48 hours. He was discharged home on day 3 and total bilirubin decreased to 2.8 mg/dL. At a follow up visit, he was asymptomatic and demonstrated WHO performance score of 1.
Hepatogastrostomy and other EUS-guided biliary drainage techniques provide minimally invasive biliary decompression and improves quality of life compared to percutaneous drainage.
This video provides a point-by-point demonstration of the technique using schematics and an actual case. We also describe indications, contraindications, limitations, and adverse events of this technique. Our readers would find this video extremely useful in replicating this technique at their institutions.
Watch the video here.
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