Post written by Hidenobu Hara, MD, from the Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan.

EUS-guided hepaticogastrostomy (EUS-HGS) has become an effective method for biliary drainage, particularly in cases of hilar bile duct obstruction.

This report presents the case of an 84-year-old woman with unresectable perihilar cholangiocarcinoma of bismuth type IV. She had occluded stents placed via the transpapillary route, and her jaundice was ultimately alleviated by a novel bilateral biliary decompression method using EUS-HGS with bridging stenting. This approach used the partial stent-in-stent method for re-intervention after multiple metal stent failures.

Initially, the patient received uncovered self-expandable metal stents (UCSEMSs) for bile duct drainage using a transpapillary approach to the posterior and anterior bile ducts. Because of left portal vein obstruction, the left segment remained undrained.

One month later, she experienced stent dysfunction in the posterior segment, and another UCSEMS was placed. Recurrent biliary obstruction was managed with plastic stents inserted within the UCSEMS. However, 3 months later, stent dysfunction recurred, complicating further transpapillary re-intervention because of malignant duodenal stenosis.

Re-intervention was attempted via EUS-HGS. Using an upper endoscopy, we removed the plastic stent. A convex echoendoscope guided placement of a hydrophilic guidewire into the posterior bile duct. The stent mesh was dilated with balloon and spiral dilators before placement of a larger guidewire for stability.

Subsequently, a second hydrophilic guidewire was placed in the anterior bile duct. The anterior bile duct stent was implanted first, followed by a second stent in the posterior bile duct using the partial stent-in-stent method to prevent overexpansion.

The HGS fistula was dilated using a spiral dilator, and a plastic stent was deployed from the posterior bile duct into the HGS fistula. Postprocedure, the patient showed significant improvement in biliary drainage, confirmed by CT scans and blood tests, with bilirubin levels dropping from 11.3 mg/dL to 0.7 mg/dL over 6 months. The patient was later placed on palliative care. When malignant gastric outlet obstruction became apparent, a duodenal stent was inserted.

This innovative approach to EUS-HGS and the partial stent-in-stent method demonstrates successful re-intervention after transpapillary multistenting. It offers a viable solution for similar complex cases, highlighting the potential of EUS-HGS in managing challenging biliary obstructions.

EUS-HGS using the partial stent-in-stent method potentially serves as salvage therapy for biliary obstruction (especially for recurrent stent dysfunction) when transpapillary drainage is technically infeasible. This case showed long-term stent patency achieved through drainage using EUS-HGS.

Our experience invites further research of efficacy and long-term stent patency of this technique, especially for complex drainage of the right lobe.

Pre– and post–EUS-guided hepaticogastrostomy 3-dimensional (3D) CT images. A, Preprocedural 3D image. B, Postprocedural 3D image.

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