Vivek Kumbhari, MD from the Department of Medicine and Division of Gastroenterology and Hepatology at The Johns Hopkins Medical Institutions in Baltimore, Maryland, USA shares this video case “EUS-guided biliary drainage made safer by a combination of hepaticogastrostomy and antegrade transpapillary stenting.”
A 61-year-old male presented with malignant biliary obstruction secondary to locally advanced pancreatic adenocarcinoma. The duodenum was distorted and biliary access was not possible with ERCP. Transgastric puncture and passage of a guidewire into the duodenum followed by dilation of the biliary stricture and hepaticogastrostomy fistula to 4mm was performed. Antegrade insertion of an uncovered self-expandable metallic stent (SEMS) across the distal biliary stricture and major papilla was then performed. A fully covered SEMS was then inserted across the hepaticogastrostomy. The patient was discharged the following day and was suitable to undergo palliative chemo-radiotherapy.
There are multiple methods and routes of access to facilitate EUS-guided biliary drainage. Currently, the literature has not definitively demonstrate one approach to be superior to another. We believe that whatever the approach, a durable response should be attained with a minimal risk of re-intervention. Additionally, steps should also be taken to minimize the risk of adverse events (unintentional perforation, bile leakage etc). Combining an antegrade biliary stent with a hepaticogastrostomy allows two routes for bile to drain and minimizes the risk of bile leakage.
Figure 1. Fluoroscopic image during dilation of the hepaticogastrostomy fistula with a 4-mm balloon. This facilitated easy insertion of the antegrade and hepaticogastrostomy self-expandable metallic stents.
We believe that antegrade stenting is a favorable option in patients with distal biliary obstruction. Our experience suggests that it is much easier to insert a guidewire in an antegrade fashion from the left main hepatic compared to the proximal common bile duct to the duodenum.
There is currently no validated algorithm that can be utilized by those performing EUS-guided biliary drainage. Most operators favor a rendezvous procedure but it is unknown whether the extrahepatic or left intrahepatic duct should be accessed to facilitate this. If a rendezvous is not possible, should the next step be an antegrade stent or choledochoduodenostomy? If antegrade stenting fails, should a hepaticgastrostomy be performed or should new access be created by performing a choledochoduodenostomy? There is a desperate need to seek answers to these questions to help construct and subsequently validate an algorithm for those performing these procedures.
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