EUS-guided hepaticojejunostomy

Takeshi Ogura, MD, PhD and Kazuhide Higuchi, MD, PhD from the 2nd Department of Internal Medicine at Osaka Medical College in Osaka, Japan present this video case “EUS-guided hepaticojejunostomy combined with antegrade stent placement.”

In our video, we described technical tips of endoscopic ultrasound-guided hepaticojejunostomy (EUS-HJS) combined with EUS-guided antegrade stenting. This patient was admitted to our hospital because of obstructive jaundice due to gastric cancer recurrence. Because this patient underwent total gastorectomy with Roux-en-Y procedure, we performed EUS-guided biliary drainage. First, we advanced the echoendoscope into the jejunum, and imaged the intrahepatic bile duct. Using a 19G FNA needle, we punctured the intrahepatic bile duct (segment 3; B3). After contrast medium was injected, we inserted the 0.025 inch guidewire. After that, we exchanged the FNA needle to the endoscopic retrograde cholangiopancreatography (ERCP) catheter. Next, the guidewire was successfully introduced into the intestine across the stenosis site, and we inserted the metallic stent delivery system. Antegrade stenting was performed above the ampulla of Vater. Finally, we performed EUS-HJS without any adverse events.

Recently, EUS-guided biliary drainage was widely performed as alternative biliary drainage method by experienced endoscopists. Although technical success rate was relatively high, rate of adverse event is also high. Especially, adverse events of EUS-guided hepaticogastrostomy (EUS-HGS) including HJS are sometimes severe such as bile peritonitis, and stet migration. During EUS-HGS procedure, there is possible risk of bile peritonitis caused by bile leak from the dilated bile duct into the abdominal cavity during dilation of the fistula, since biliary obstruction is still present.

For this reason, EUS-HGS combined with antegrade stenting (EUS-HGAS) may have several advantages. First, the risk of bile peritonitis resulting from dilation of the fistula during EUS-HGS may be decreased because bile stasis distal to the obstruction site has already been resolved by performing EUS-AS prior to EUS-HGS. Second, because of the use of EUS-AS, if EUS-HGS stent migration were to occur, it may be safer for the patient because of placement of the EUS-HGS stent via EUS-AS. In addition, because of using two metallic stents, long stent patency may obtain compared with EUS-HGS alone.  However, if patients have no pancreatic atrophy and EUS-AS is performed across the ampulla of Vater, because endoscopic sphincterotomy (EST) cannot be performed, acute pancreatitis may occur. Therefore, EUS-HGAS should not be performed for such cases.

Although validation is required in a prospective clinical trial, our method appears to safely and effectively prevent adverse events associated with EUS-BD. When EUS-BD is performed, EUS-AS should be performed, if possible, because this procedure may have sometimes severe adverse events.

Find more VideoGIE articles here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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