Post written by Yingluk Sritunyarat, MD, from the Gastrointestinal Endoscopy Excellence Center, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.

Traditionally, the treatment for bile duct transection is surgical-created bilio-enteric bypass. With recent advanced techniques to avoid the need for surgery, the magnetic-compression technique can recanalize the bile duct back to an original duct-to-duct anastomosis. Typically, the lower magnet can be placed via the papilla under ERCP guidance. However, percutaneous puncture with external catheter left for a few weeks to create a mature tract is required before the proximal magnet placement can be placed. This external catheter may cause pain and discomfort to the patient. In our video case, we avoided the external puncture by using the internal access instead. An internal hepaticogastrostomy was created by EUS guidance to avoid the discomfort from the external catheter.    

This is the first case demonstrating the total internal access of the 2 magnet placements, one was from the standard transpapillary approach and the other was from the hepaticogastric fistula created by EUS guidance.

The steps to create hepatic-gastrostomy in this particular situation are unique.

1. The segment selection can be either segment II or III of the liver, but esophageal puncture should be avoided.
2. For the first stent used to create the fistula, we recommend a double pigtail plastic stent not a partially covered self-expandable metallic stent, otherwise the stent could not be removed or replaced.
3. There was a need for the second session to upsize the fistula tract and maintain it with a short fully covered self-expandable metallic stent. The objective of this stent is to be used as a bridge to access the left intrahepatic duct and place the proximal magnet. This short stent should not be used during the first session because there is a risk for stent migration.

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