Takeshi Ogura, MD, PhD from the Second Department of Internal Medicine, Osaka Medical College in Osaka, Japan shares this VideoGIE case “Antegrade biopsy by using a trans-catheter technique through EUS-guided hepaticojejunostomy.”
In our video, we described technical tips of antegrade biopsy and blushing cytology through endoscopic ultrasound-guided hepaticojejunostomy. First, we punctured the intrahepatic bile duct (segment 3; B3) using 19G needle across the jejunum. Then, a small amount of bile juice was aspirated and contrast medium was injected. After imaging of biliary tree was obtained, we inserted 0.025 inch guidewire into the bile duct. Lower bile duct was obstructed, and advanced the guidewire into the intestine across ampulla of Vater using endoscopic retrograde cholangiopancreatography (ERCP) cannula. And then, we inserted a dilator (SBDC-9, Soehendra Biliary Dilation Catheter, Cook Medical, Bloomington, IN, USA) to the site of bile duct obstruction through a dilator catheter, and performed forceps biopsy. Next we performed brushing cytology. Result of on-site rapid evaluation was confirmed as recurrent gastric cancer. Therefore, we performed EUS-guided hepaticojejunostomy using metallic stents (10mm×10cm, end bare type, Niti-S Biliary Covered Stent). No adverse events were seen.
Recently, EUS-guided biliary drainage was widely performed as an alternative biliary drainage method by experienced endoscopists. However, these novel techniques have high rate of adverse events, and long-term results are not clear. Therefore, EUS-BD may be indicated for patients who had unresectable malignant tumors. All treatments including chemotheraphy or EUS-BD require the cytological or histological evidence. This fact is extremely important to avoid misdiagnosis.
However, if we cannot perform EUS-FNA or biopsy and cytology under ERCP guidance such as Roux-en-Y anastomosis, obtaining tissue samples is difficult. On the other hand, using our method, re-biopsy or re-brush cytology was able to easily be performed across the dilator. In addition, if we can perform antegrade biopsy and brushing cytology using rapid on-site evaluation by a cytopathologist, allowing determination of whether a lesion is malignant or benign during the procedure. If biopsy or cytological results show a benign lesion, we place a plastic stent across the stricture and the endoscopic nasal biliary drainage tube into the common bile duct to avoid bile leakage. If the results show malignancy, we place a metallic stent from the intrahepatic bile duct to the jejunum.
EUS-guided access has clinical impact not only as a diagnostic modality but also as a technique to obtain cytological or histological evidence.
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