EUS-guided hepaticogastrostomy of a difficult-to-access biliary obstruction involving the caudate lobe (with video).

Abstract

EUS-guided hepaticogastrostomy (EUS-HGS) has been increasingly used as an alternative approach to percutaneous biliary drainage after failed transpapillary drainage.[1,2] EUS-HGS is often performed via the B2 or B3 bile ducts due to the proximity of these biliary branches with the stomach. The B1 bile duct at the caudate lobe is considered one of the difficult-to-access bile ducts for percutaneous biliary drainage given its distance from the skin surface. EUS is advantageous in accessing the B1 bile duct given its proximity to the stomach;[3-5] however, to the best of our knowledge, no studies have reported performing EUS-HGS via the B1 bile duct. Herein, we report a case where biliary obstruction involving the B1 bile duct was successfully managed via EUS-HGS. A 97-year-old woman was referred to our hospital for fever and abdominal pain. She had a history of recurrent cholangitis due to benign sclerosing cholangitis. Magnetic resonance imaging (MRI) revealed intrahepatic bile duct dilation in the caudate lobe [Figure 1]. Initially, endoscopic transpapillary drainage was attempted; however, due to severe stricture, the B1 bile duct was not visualized by the cholangiogram. Subsequently, EUS-HGS was planned. Clockwise rotation of the echoendoscope after identification of the lateral liver lobe from the stomach enabled the clear visualization of the B1 bile duct [Figure 2]. The dilated B1 bile duct was punctured using a 19-gauge aspiration needle [Figure 3], and the puncture tract was dilated using a bougie dilator. A dedicated 7-Fr × 14-cm plastic stent (TYPE-IT Stent; Gadelius Medical, Tokyo, Japan) was deployed between the B1 bile duct and stomach [Figure 4 and Video 1]. The patient’s condition improved within a few days, and MRI performed after the procedure revealed a well-drained B1 bile duct [Figure 5]. Currently, cholangitis has not recurred over 6 months after the procedure.Figure 1: Magnetic resonance imaging showing biliary dilation of the B1 bile duct localized at the caudate lobe (arrowheads)Figure 2: EUS shows the B1 bile duct via the gastric wall by clockwise rotation of the echoendoscope after identification of the lateral liver lobe (arrowheads)Figure 3: EUS-guided hepaticogastrostomy for the B1 bile duct. The dilated B1 bile duct was punctured with a 19-gauge aspiration needle. (a) EUS image; (b) fluoroscopic imageFigure 4: A dedicated 7-Fr × 14-cm plastic stent (TYPE-IT Stent; Gadelius Medical, Tokyo, Japan) was successfully deployed between the B1 bile duct and stomach. (a) Endoscopic image; (b) fluoroscopic imageFigure 5: MRI showing a well-drained B1 bile duct. MRI (a) before and (b) after drainage. MRI: Magnetic resonance imaging {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_x2u5iac6"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} This case highlighted the usefulness of an alternative EUS approach to the B1 bile duct, which is generally difficult to approach percutaneously. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.