EUS-guided Hepaticogastrostomy Research Articles

Efficacy and safety of endoscopic ultrasound-guided hepatico-gastrostomy: a meta-regression analysis.

EUS-guided hepaticogastrostomy (EUS-HGS) is a valid option for EUS-guided biliary drainage that has been increasingly used in the last decade. The aims of the study were to provide a systematic review with meta-analysis and meta-regression of features and outcomes of this procedure. MEDLINE, Scopus, Web-of-Science, and Cochrane databases were searched for literature pertinent to EUS-HGS. Meta-analysis of proportions and meta-regression of potential modifiers of the main outcome measures were applied. The main outcome was technical success. Secondary outcomes were clinical success and procedure-related adverse events (AEs). Thirty-three studies including 1644 patients were included in the meta-analysis. Malignant biliary obstruction was the underlying cause in almost all (99.6%) cases; the main indications for EUS-HGS were duodenal/papillary invasion (34.8%), surgical altered anatomy (18.4%) and hilar stenosis (16%). Pooled technical success of EUS-HGS was 97.7% (95%-CI: 96.1-99%, I2=0%), the intention to treat (ITT) clinical success was 88.1% (95%-CI: 84.7-91.2%, I2=33.9%) and procedure-related AEs occurred in 12% (95%-CI: 9.8-14.5%, I2=20.4%), being cholangitis/sepsis (2.8%) and bleeding (2.3%) the most frequent. The rate of procedure related AEs was reduced with the use of dedicated stents at the univariable meta regression analysis. Meta-regression showed that technical success and clinical success rates were modified by centers' experience (>4/year). EUS-HGS represents an effective and safe procedure for EUS-guided biliary drainage in patients with malignant biliary obstruction. Future studies should address the impact of center experience, patient selection, and use of dedicated stents to improve this technique's performance.

A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure

A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure

EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis.

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.

Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer.

Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease.

Successful endoscopic re-interventions through EUS-guided hepaticogastrostomy route

Successful endoscopic re-interventions through EUS-guided hepaticogastrostomy route

Severe portal venous bleed during ERCP treated with EUS-guided hepaticogastrostomy.

Video 1Severe portal venous bleed during ERCP treated with EUS-guided hepaticogastrostomy.

Outcomes of Endoscopic Biliary Drainage in Postsurgical Anatomy Using Endoscopic Ultrasound and Enteroscopy: A Comparative Study

AbstractObjectives Biliary obstruction is a common problem encountered in postsurgical anatomy, which may lead to serious complications if not treated promptly. Endoscopic drainage is a minimally invasive and effective treatment option for such patients. However, the optimal route of endoscopic drainage, either SBE-ERCP (single-balloon enteroscopy with endoscopic retrograde cholangiopancreatography) or EUS-BD (endoscopic ultrasound-guided bile duct drainage), remains controversial. In this study, we aim to evaluate the feasibility and outcomes of endoscopic drainage using these two techniques in postsurgical biliary obstruction over a period of 7 years.Materials and Methods We conducted a retrospective study of patients who underwent endoscopic drainage for postsurgical biliary obstruction using SBE-ERCP or EUS-BD techniques between 2015 and 2022. The demographic details, clinical presentation, procedure duration, number of sessions required, technical success, complications, and change of procedure from SBE-ERCP to EUS-BD or vice versa were recorded.Results Seventy-five patients, predominantly females with a mean age of 48 years, underwent endoscopic drainage. Forty-eight patients underwent SBE drainage and 27 patients underwent EUS-HG (EUS-guided hepaticogastrostomy). The mean duration of procedure (44 vs. 77 minutes), number of complications (4 vs. 5), technical success rate (93.5 vs. 85%), change of procedure (0 vs. 3), and number of sessions (1.1 vs. 1.8) were significantly less in the EUS-HG as compared to SBE-ERCP.Conclusions Endoscopic biliary drainage is feasible, safe, and effective in postsurgical biliary anatomy but requires high technical expertise. The study proposes an algorithm that can be applied in such group of patients to determine the route for choosing the drainage procedure. This requires further validation with a large prospective cohort.

Endoscopic Ultrasonography-Guided Biliary Drainage: Experience of a Moroccan Center

Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new therapeutic modality in the arsenal of endoscopists for attaining satisfactory biliary drainage when traditional ERC fails. The aim of our study is to describe the first Moroccan experience with EUS-BD in patients with malignant biliary obstruction after a failed or inaccessible ERCP. Methods: This is a retrospective study conducted at Ibn Sina Hospital, from Mars 2018 to July 2022, which include 27 patients with an inoperable or metastatic malignant biliary obstruction who underwent endoscopic ultrasonography-guided biliary drainage (EUS-BD) in case of endoscopic retrograde cholangiopancreatography (ERCP) failure. Results: From a total of 288 patients with malignant biliary obstruction,27 underwent EUS-BD (9,3%), 15 EUS-guided hepaticogastrostomy (55,5%) and 12 EUS-guided choledocoduodenostomy (44,4%) were performed. The mean age was 62.5 years (age range: 23-74 years), a male predominance of 59% was noted, cholestatic jaundice was present in 100% of patients and associated with pruritus in 92.59% of cases. The mean level of Total Bilirubin was 190 mg/l. The causes of biliary obstruction were: an inoperable pancreatic head mass in 13 patients(48,1%), a cholangiocarcinoma in 7 patients (25.9%), an ampullary mass in 4 patients(14,8%), a gallbladder cancer with hepatic and duodenal invasion in one patient (3,7%), a gastric antropyloric adenocarcinoma with pancreatic head invasion in one patient (3,7%) and Duodenal adenocarcinoma in one patient (3,7%).The leading causes of failed ERCP were secondary to tumor infiltration of the duodenal wall and critical duodenal stenosis in 11 cases (40,7%), in 9 cases due to a difficult cannulation (33.3%) and in 7 cases due to a failure to pass the stricture by ERCP (25.9%). In EUS-HG The technical and the clinical success rates were 86.6% (13/15) and 84.6% (11/13), respectively, the complication rate was 13.3% (2/15) including one case of stent migration complicated with bile leak and one case of cholangitis. In EUS-CD The technical and the clinical success rates were 91.6% (11/12) and 81.8% (9/11)), respectively, the complication rate was 16.6% (2/12) including two cases of cholangitis. The technical and the clinical success rates in all EUS-BD were 85.1% (24/27) and 83.3% (20/24), respectively. The complication rate was 14.8% (4/27). Conclusion: EUS-BD appears to be an effective and safe therapeutic option for biliary decompression in cases where ERCP fails.

Preliminary feasibility study of a new partially covered self-expandable metal stent with an anchoring flange for EUS-guided hepaticogastrostomy (with videos)

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has a risk of serious procedural adverse events (AEs), but few dedicated devices for EUS-HGS are available. We evaluated the feasibility of a new partially covered self-expandable metal stent (PCSEMS) with an anchoring flange for EUS-HGS. The feasibility of a stent featuring a proximal radiopaque uncovered portion 1.5 cm in length and a distal anchoring flange 20 mm in diameter was evaluated in consecutive patients undergoing EUS-HGS for unresectable malignant biliary obstruction. The primary outcome was technical and clinical success with regard to the EUS-HGS, and the secondary outcomes were adverse events (AEs), recurrent biliary obstruction (RBO), re-intervention for RBO, and the technical feasibility of peroral cholangioscopy (POC) through the stent in situ. EUS-HGS was performed in 24 patients with unresectable malignant biliary obstruction. The technical and clinical success rates of EUS-HGS were 100% (24/24) and 91.7% (22/24), respectively. AEs developed after EUS-HGS in 8.3% of the patients (2/24, cholangitis). RBO developed in 29.2% of the patients (7/24), with a median cumulative time to RBO of 6.7 months. The causes of RBO were sludge formation (n = 4), hyperplasia at an uncovered portion (n = 2), and nonocclusive cholangitis (n = 1). Re-intervention for RBO had a 100% success rate (7/7), and POC through the stent in situ was technically feasible in seven out of eight patients with a stent diameter of 10 mm. EUS-HGS with a new PCSEMS can alleviate malignant biliary obstruction after failed ERCP. The novel stent evaluated in this study may prevent stent-related AEs including stent migration and allow advanced endoscopic interventions through the HGS route.

Endoscopic ultrasound-guided hepaticogastrostomy versus choledochoduodenostomy for malignant biliary obstruction: A meta-analysis.

Endoscopic ultrasound (EUS)-guided biliary drainage encompasses techniques such as EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). This meta-analysis compared the efficacy of EUS-CDS with that of EUS-HGS for the treatment of biliary obstruction. A systematic meta-analysis of all relevant articles listed was performed by searching the Cochrane Library, PubMed, and Google Scholar databases. We used random effects or fixed effects models to compare success rates, adverse events, procedure times, and time to recurrent biliary obstruction after EUS-CDS and EUS-HGS. This meta-analysis included 18 eligible studies. There was no significant difference between EUS-CDS and EUS-HGS with respect to technical success rate (odds ratio [OR] 1.04; 95% confidence interval [CI] 0.62-1.73) and clinical success rate (OR 0.66; 95% CI 0.43-1.04), or with respect to total procedure-related adverse events (OR 1.39; 95% CI 1.00-1.93). Subgroup analysis of adverse events revealed that the rate of recurrent biliary obstruction (RBO) was significantly higher for EUS-HGS (OR 2.95; 95% CI 1.54-5.64). There was no significant difference between the two methods with respect to time to recurrent biliary obstruction (mean difference -11.93 days; 95% CI -47.77-23.91). However, the procedure time was longer for EUS-HGS (mean difference, 3.21 min; 95% CI 1.24-5.19). EUS-CDS and EUS-HGS are comparable in terms of technical success, clinical success, and rate of adverse events; however, EUS-CDS is superior with respect to procedure time and preventing RBO.

Clinical evaluation of a novel drill dilator as the first-line tract dilation technique during EUS-guided biliary drainage by nonexpert hands (with videos).

In cases in which tract dilation fails using the initially selected dilation device during EUS-guided hepaticogastrostomy (EUS-HGS), dilation should be re-attempted using another device. However, switching from one device to another during the procedure is often associated with prolonged procedure time and deviation from the correct axis. Therefore, it is highly desired that the initial tract dilation succeeds on the first attempt. Recently, a novel drill dilator has become available in Japan. Because there have been no previous studies comparing this novel device versus others as an initial dilation device, this article reports on the technical feasibility of this novel device for use during EUS-HGS and compares it with a balloon catheter. This retrospective study included patients who underwent EUS-HGS using a self-expandable metal stent between October 2021 and October 2022. Excluded from the study were patients who underwent EUS-HGS using a plastic stent or stent deployment without tract dilation. The primary outcome in this study was the technical success rate of initial tract dilation using the drill dilator. This dilator has been available at our hospital since June 2022. Thus, EUS-HGS was performed using this device as the primary dilation device from June 2022 to October 2022. As the control group, we corrected patients who underwent EUS-HGS using a 4-mm balloon catheter as the primary dilation device from October 2021 to May2022. A total of 49 patients were included: 19 underwent EUS-HGS using the drill dilator and 30 underwent EUS-HGS using a balloon catheter. EUS-HGS using the drill dilator initially was performed mainly by nonexpert hands (n= 19), whereas only some procedures in the balloon catheter group were performed by nonexpert hands (n= 2). Although the initial tract dilation was successful in all patients in the drill dilator group (19 of 19 [100%]) and in 29 (97%) of 30 in the balloon catheter group, additional tract dilation was needed in 73.7% (14 of 19) of the drill dilator group upon insertion of the 8.5F stent delivery system. In contrast, the stent delivery system insertion was successful without additional tract dilation in all patients in the balloon catheter group. The novel drill dilator might be useful as a dilation device; however, the balloon dilation technique should be selected first upon deploying a dedicated metal stent with an 8.5F stent delivery system.

Rescue technique for bleeding after placement of plastic stent in EUS-guided hepaticogastrostomy (with videos).

Rescue technique for bleeding after placement of plastic stent in EUS-guided hepaticogastrostomy (with videos).

Tips and tricks for endoscopic ultrasound-guided hepaticogastrostomy.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a treatment option for patients with biliary obstruction in whom traditional endoscopic retrograde cholangiopancreatography (ERCP) is not possible due to altered upper gastrointestinal anatomy. In such cases, EUS-BD is a good alternative to surgery or percutaneous transhepatic biliary drainage (PTBD), with comparable clinical and technical success rates [1]. Two approaches have been described for EUS-guided transluminal biliary drainage. EUS-guided hepaticogastrostomy uses the transgastric approach and EUS-guided choledochoduodenostomy uses the transduodenal approach [2].

With a little help from my friends: percutaneously assisted internalization of a biliary drain.

Video 1Narrated case of an EUS-guided hepaticogastrostomy facilitated by opacification and distention of the left intrahepatic ducts using an existing percutaneous drain tract.

Comparison of recurrent biliary obstruction with the use of metal and plastic stents in EUS-guided biliary drainage: A propensity score-matched analysis.

In transpapillary biliary drainage, metal stents (MSs) exhibit a lower incidence of a biliary obstruction than plastic stents (PSs). However, few studies have compared recurrent biliary obstruction (RBO) when MSs and PSs are used in EUS-guided hepaticogastrostomy (EUS-HGS) and choledochoduodenostomy (EUS-CDS). We retrospectively evaluated the RBO for both stents in each procedure. : Between November 2012 and December 2020, 85 and 53 patients who underwent EUS-HGS and EUS-CDS for unresectable malignant biliary obstruction, respectively, were enrolled. Factors associated with RBO were assessed. Clinical outcomes were compared between the MS and PS groups using propensity score matching. : The clinical success rate and procedure-related adverse events were similar in the MS and PS groups. Multivariate analysis identified the use of PS as a factor associated with RBO (EUS-HGS, P = 0.03; EUS-CDS, P = 0.02). After matching, the median time to RBO in EUS-HGS (MS: 313; PS: 125 days; P = 0.01) in the MS group was longer than that in the PS group. The cumulative incidence of RBO at 1, 3, and 6 months in the MS group was significantly lower than that in the PS group for EUS-HGS (MS: 4.0%, 8.2%, and 8.2%; PS: 12.4%, 24.9%, and 39.5%, respectively, P = 0.01). : MS exhibited a lower rate of RBO than PS for EUS-HGS and EUS-CDS.

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

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.

A pilot study of Spring Stopper Stents: Novel partially covered self-expandable metallic stents with anti-migration properties for EUS-guided hepaticogastrostomy.

EUS-guided hepaticogastrostomy (EUS-HGS) is an effective salvage procedure when conventional endoscopic transpapillary biliary drainage is difficult or fails. However, the risk of stent migration into the abdominal cavity has not been resolved completely. In this study, we evaluated a newly developed partially covered self-expandable metallic stent (PC-SEMS) that has a spring-like anchoring function on the gastric side. This retrospective pilot study took place at four referral centers in Japan between October 2019 and November 2020. We enrolled 37 cases consecutively who underwent EUS-HGS for unresectable malignant biliary obstruction. The rates of technical and clinical success were 97.3% and 89.2%, respectively. Technical failures included one case in which the stent was dislocated during the removal of the delivery system, requiring additional EUS-HGS on another branch. Early adverse events (AEs) were observed in four patients (10.8%): two with mild peritonitis (5.4%) and one each (2.7%) with fever and bleeding. No late AEs were observed during the mean follow-up period of 5.1 months. All recurrent biliary obstructions (RBOs) were stent occlusions (29.7%). The median cumulative time to RBO was 7.1 months (95% confidence interval, 4.3 to not available). Although stent migration in which the stopper was in contact with the gastric wall on follow-up computed tomography was observed in six patients (16.2%), no migration was observed. The newly developed PC-SEMS is feasible and safe for the EUS-HGS procedure. The spring-like anchoring function on the gastric side is an effective anchor preventing migration.

EUS-guided hepaticogastrostomy in multimetastatic liver disease - an effective approach for biliary drainage that may complement ERCP.

A 36-year-old male was diagnosed with a metastasized colon adenocarcinoma causing obstructive jaundice. Magnetic resonance cholangiography showed a dominant lesion causing hilar stenosis. The patient was submitted to endoscopic retrograde cholangiopancreatography (ERCP), nevertheless it was just possible to place a single uncovered self-expandable metallic stent (SEMS) in the right lobe. Although cholestasis significantly improved, safe levels for oncologic therapy were not reached. EUS-guided hepaticogastrostomy was proposed to complement ERCP biliary drainage. Using a forward-viewing echoendoscope and a transgastric approach, EUS-guided puncture of a dilated left intrahepatic duct at segment III was accomplished with a 19G needle (EchoTip ProCore®) that allowed passage of a 0.035 guidewire. A 6F cystotome and biliary dilators (5Fr+8.5Fr) were used for needle tract dilation. A partially-covered SEMS (GIOBOR™ 8x100mm) could be deployed under endoscopic and fluoroscopic control, being placed 3cm inside the gastric lumen. No associated complications were observed after the procedure.

Liver impaction technique improves technical success rate of guidewire insertion during EUS-guided hepaticogastrostomy (with video).

If the guidewire becomes kinked by the needle, guidewire manipulation may be difficult, and can cause complications such as guidewire shearing or injury during endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS). To overcome this matter, we have previously described a technical tip for preventing guidewire injury, termed 'liver impaction technique'. However, its technical feasibility has been not reported in the setting of a large patient cohort. The aim of study was to evaluate the clinical usefulness of the liver impaction technique during EUS-HGS. Retrospective, single-center study. This retrospective study included consecutive patients who underwent EUS-HGS between April 2018 and September 2022. The primary outcome of this study was the technical success rate of guidewire insertion using the liver impaction technique. A total of 166 patients were enrolled in this study. Initial successful guidewire insertion without using liver impaction technique was obtained in 108 patients (65.1%). Among 58 patients in whom guidewire insertion failed initially, guidewire advancement into the periphery of the bile duct was observed in 32 patients (55.2%) and into a non-interest bile duct branch was observed in 26 patients (44.8%). Liver impaction technique contributed to increasing the technical success rate of guidewire insertion from 65.1% to 95.8%. Overall, adverse events were observed in 12 patients (7.2%; bile peritonitis n = 9, cholangitis n = 3), and these adverse events were Grade I. Among patients who underwent liver impaction technique (n = 58), adverse events were observed in two patients (3.4%; bile peritonitis). Also, guidewire sharing was not observed in any patients during liver impaction technique. In conclusion, the liver impaction technique may be helpful during EUS-HGS to obtain successful guidewire insertion into the biliary tract of interest.

Spy basket retrieval method of an embedded hepaticogastrostomy stent (with videos).

EUS-guided hepaticogastrostomy (EUS-HGS) is performed for benign biliary diseases as an alternative therapy for ERCP. However, a critical adverse event such as stent migration was reported.[1] Recently, stent retrieval method in the HGS route using Spy bite (Boston Scientific, Marlborough, Massachusetts, USA),[2] forceps,[3] or balloon[4] has been reported. We report a case that the plastic stent (PS) retrieval method using Spy basket (Boston Scientific) [Figure 1] and grasping the flap of PS was efficient as a new stent retrieval method.Figure 1: Spy basket (Boston Scientific, Marlborough, Massachusetts, USA)A 70-year-old man with a history of pancreaticoduodenectomy was admitted to our institution to treat intrahepatic biliary stones. Because we failed to remove stones under enteroscope-assisted ERCP due to the instability of the scope, we decided to perform EUS-HGS. At first, a PS was placed in the choledochojejunostomy route, and a metallic stent was placed across the HGS route due to the incomplete stone extraction because of large stone size [Video 1]. One month later, the PS was revealed to be placed into B2 [Figure 2a]. It seemed to be difficult to retrieve the PS because of embedding into not B3 but B2. After we removed the metallic stent in the HGS route, cholangioscope (Spy-Glass DS; Boston Scientific) was inserted. Although we failed to catch the PS by Spy bite under direct visualization [Video 2], we could successfully grasp the flap of embedded stent and easily retrieve it using a Spy basket [Figure 2b, c and Video 3]. Finally, stones were completely extracted using electrohydraulic lithotripsy with a cholangioscopy. No procedure-related adverse events occurred [Figure 2d]. Although stent dislocation can be a serious complication during interventional EUS and may need surgical intervention, cholangioscopy-guided grasping the flap of PS by Spy basket can be an effective method for retrieval of embedded PS.Figure 2: Retrieval of an embedded stent using a digital cholangioscopy and Spy basket; (a) An embedded plastic stent to the left lateral branch of the bile duct (B2). (b and c) The embedded stent was grasped using a Spy basket under digital cholangioscopic visualization, on the cholangioscopic image and fluoroscopic image. (d) Fluoroscopic image of the biliary duct after removal of the stent and intrahepatic biliary stonesDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.