Post written by Ryan Law, DO, from the Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.

We present a case of a 59-year-old man with stage IV colorectal cancer with extensive metastatic disease to his liver who underwent EUS-guided internalization of his percutaneous transhepatic biliary drainage (PTBD) catheter utilizing an EUS-guided hepaticogastrostomy (EUS-HGS) approach. The patient had developed a high-grade biliary obstruction at the level of the left main hepatic duct and underwent PTBD for decompression. Two attempts at internalization of biliary drainage with ERCP were unsuccessful. He was then referred for EUS-HGS to internalize his percutaneous biliary drainage catheter. EUS-HGS was successfully performed without adverse events, and the PTBD catheter was removed immediately. The patient was discharged home and survived 3 months without biliary adverse events.

This video demonstrates the use of EUS-guided biliary drainage techniques to internalize biliary drainage in a patient otherwise destined for lifelong percutaneous transhepatic biliary drainage following disease progression of metastatic colorectal cancer. These evolving interventional EUS techniques may provide an alternative option in patients with similar circumstances.

EUS-guided hepaticogastrostomy can provide internal biliary drainage without traversing the strictured segment, as is necessary for internalization using ERCP or percutaneous techniques. Recent data suggests this technique is technically-feasible, safe, and should be considered if EUS-guided biliary drainage expertise is available.

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