Post written by Rishi Pawa, MD, FACG, from the Wake Forest School of Medicine, Winston-Salem, North Carolina.

A 43-year-old woman with history of Roux-en-Y hepaticojejunostomy (secondary to Strasberg type E1 common bile duct injury at the time of her cholecystectomy) presented with cholangitis, hepatolithiasis, and hepaticojejunostomy (HJ) anastomotic stricture. She initially underwent an EUS-guided hepaticogastrostomy (EUS-HG) for biliary drainage for cholangitis. A repeat ERC was performed after 4 weeks via the HG tract with cholangioscopy, electrohydraulic lithotripsy (EHL), balloon sweeps for removal of intrahepatic stones, and dilation of the HJ anastomotic stricture with placement of plastic double pigtail stent across the stricture. Follow-up ERC and cholangioscopy showed patent HJ anastomosis with no residual stone disease in the biliary tree. The HG stents were removed, and follow-up LFTs were normal.   

EUS-HG has emerged as a novel endoscopic technique for management of obstructive biliary diseases in patients with surgically altered GI anatomy. EUS-HG has a high success rate and fewer adverse events than percutaneous transhepatic biliary drainage (PTBD) or surgery, thereby making it an excellent management option following failed ERCP. Innovations in the development of EUS-HG specific tools coupled with standardization of technique will likely lead to its dissemination and improved safety. 

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