Post written by Hassan Atalla, MSc, and Hideyuki Shiomi, MD, PhD, from the Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan, and Hepatology and Gastroenterology Unit, Department of Internal Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt.

A 69-year-old woman who had undergone a distal gastrectomy combined with Roux-en-Y reconstruction for gastric cancer had hilar malignant biliary obstruction (MHBO) due to liver metastasis. We performed EUS-guided transluminal treatment combined bridging and antegrade stenting.   

Bilateral biliary drainage has been considered as the recommended approach for MHBO. Patients with surgically-altered anatomy usually represent a challenge for enteroscopy-assisted ERCP (E-ERCP) with its demanding procedure and dedicated technique. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has become a feasible alternative approach for this group of patients, allowing bilateral drainage through the bridging technique. Furthermore, combined EUS-HGS with antegrade common bile duct (CBD) stenting can prolong the stent patency mostly related to securing the natural antegrade bile flow. Therefore, expecting long-term stent patency, we attempted EUS-HGS combined bridging and antegrade stenting for MHBO in a patient with surgically altered anatomy.

MHBO in patients with surgically altered anatomy usually represent a challenge for endoscopic therapeutic modalities. However, this transmural procedure appears to be a feasible, potentially safe, and effective treatment option for MHBO in this category of patients.

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