Endoscopic ultrasound-guided hepaticogastrostomy: Problems and solutions; some unsuccessful and then the right one!

Abstract

A 36-year-old male presented with obstructive jaundice and acute pancreatitis. Both imaging and an upper gastrointestinal endoscopy revealed malignant duodenal obstruction involving first and second parts. The patient was managed conservatively for acute pancreatitis. Endoscopic retrograde cholangiopancreatography was not possible in view of duodenal pathology. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy was planned. Walled-off pancreatic necrosis as well as ascites was noted on EUS. Hepatic duct access was gained; a guidewire placement with track dilation using 6 Fr cystotome (Endoflex) was performed. A Giobor stent (Taewoong Medical, 8 mm × 10 cm long) was placed between the liver and stomach; immediate migration of the stent was noted resulting in to the impaction of the proximal end in to the gastric wall. Retrieval attempts made over the in-stent placement of a 7 Fr. Double pigtail plastic stent was unsuccessful. Plastic stent was removed after stent intubation carried out over a guidewire placed through the side hole. Retrieval using a Hurricane balloon (8 mm, Boston Scientific) was also unsuccessful. Eventually, successful biliary drainage was performed using both bare (10 mm × 60 mm, Taewoong Medical) biliary metal stent placement through the Giobor stent. An enteral stent (WallFlex Duodenal, Boston Scientific) was placed for the duodenal obstruction.