EUS-guided Hepaticogastrostomy Research Articles

Clinical Impact of the Intra-scope Channel Stent Release Technique in Preventing Stent Migration During EUS-Guided Hepaticogastrostomy

BackgroundsStent migration following endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) may sometimes be fatal because there are no adhesions between the biliary tract and stomach. To prevent stent migration and minimize the stent length in the abdominal cavity, we recently performed EUS-HGS using the technique of releasing the stent within the scope channel. AimsTo examine the technical feasibility of the intra-scope channel stent release technique. MethodsForty-one consecutive patients who underwent EUS-HGS were enrolled. Between October 2015 and December 2015, EUS-HGS was performed using the extra-scope channel release technique, while the intra-scope channel release technique was performed between January 2016 and March 2016. ResultsThe distance between the hepatic parenchyma and the stomach wall after EUS-HGS in the intra-scope channel stent release group was significantly shorter than that in the extra-scope channel release group (0.66±1.25 vs 2.52±0.97, P<0.05). Adverse events, such as biloma or stent migration, were seen in only the extra-scope channel release group. ConclusionIn conclusion, although additional cases and randomized controlled studies using metal stents of various lengths are needed, our technique is likely to be clinically useful for the prevention of early and late stent migration.

Endoscopic ultrasound-guided hepaticogastrostomy and antegrade clearance of biliary lithiasis in patients with surgically-altered anatomy.

Background and study aims Endoscopic retrograde cholangiography (ERC) in patients with complex surgically-altered anatomy (SAA) is technically demanding and has limitations. Developments in EUS-guided procedures allow alternative approaches for patients with altered gastrointestinal anatomy and biliary lithiasis. Patients and methods Single-center, retrospective review of prospectively entered patients with SAA who underwent EUS-guided hepaticogastrostomy (HGS) followed by an interval antegrade endoscopic clearance of biliary lithiasis. Results 9 patients with Roux-en-Y anatomy underwent HGS to allow clearance of biliary lithiasis after a mean of 2.5 procedures. Technical success was achieved in 100 % of patients utilizing subsequent antegrade endoscopic techniques after HGS including: balloon sweep (9), transpapillary balloon dilation (8), cholangioscopy with electrohydraulic lithotripsy (4), and mechanical lithotripsy (1). HGS stents were removed in all patients. 1 adverse event (cholangitis) occurred after cholangioscopy and prolonged intraductal electrohydraulic lithotripsy. Conclusion EUS-guided antegrade therapy for the management of biliary lithiasis in patients with altered gastrointestinal anatomy appears efficacious with a low risk of adverse events. These preliminary results suggest this approach should be considered at centers with available expertise.

Safety and efficacy of ultra-tapered mechanical dilator for EUS-guided hepaticogastrostomy and pancreatic duct drainage compared with electrocautery dilator (with video).

Background and Objectives:Successful tract dilation is one of the most important steps to accomplish EUS-guided drainage. Although mechanical dilation is safer than electrocautery dilation, no dedicated mechanical dilator (MD) is currently available. Thus, we developed a new ultra-tapered MD for EUS-guided drainage. This study aimed to evaluate the safety and usefulness of this novel MD.Patients and Methods:Consecutive patients who underwent EUS-guided hepaticogastrostomy (EUS-HGS) or EUS-guided pancreatic duct drainage (EUS-PD) at two centers were included in the study. Dilation of the needle tract was initially performed with a diathermic sheath or the ultra-tapered MD. Technical success and adverse events were assessed.Results:Sixty-four patients (mean age = 68.9 ± 13.8 years, 35 men) underwent EUS-HGS (49 patients) and EUS-PD (15 patients). Thirty-three patients were included in the cautery dilator (CD) group and 31 in the ultra-tapered MD group. Initial dilation of the puncture site was achieved in 95.3% (61/64): 97% (32/33) of the patients in the CD group and 93.3% (29/31) of the patients in the MD group (P > 0.05). Adverse events were observed in 14 patients: abdominal pain in 8 patients and bleeding in 6 patients at the puncture site. All bleedings occurred in the CD group and there was no patient in whom bleeding occurred after EUS intervention in the MD group (P = 0.04).Conclusion:The novel ultra-tapered MD designed for interventional EUS appears to be safe and useful as it reduced postprocedure bleeding with a high technical success rate compared with the conventional electrocautery dilator.

Stent release within scope channel technique to prevent stent migration during EUS-guided hepaticogastrostomy (with video).

Stent release within scope channel technique to prevent stent migration during EUS-guided hepaticogastrostomy (with video).

A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction.

Background and Objectives:EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed.Methods:This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD.Results:Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the First choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended.Conclusion:This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.

The intra-conduit release method is useful for avoiding migration of metallic stents during EUS-guided hepaticogastrostomy (with video).

Although EUS-guided hepaticogastrostomy (EUS-HGS) with a covered self-expandable metal stent (SEMS) is a useful procedure, it is associated with severe adverse events, including stent migration. We, therefore, developed an intra-conduit release method, and investigated whether the technique yields a safer and more stable procedure. The intra-conduit release method is a procedure to release the SEMS in the working channel conduit of the scope for anchoring between the liver and stomach to avoid stent migration. Forty-three patients who underwent EUS-HGS at two high-volume centers in Japan were enrolled in this retrospective study, and the safety and usefulness of this method were evaluated retrospectively. The intra-conduit release method was applied in 36 cases. The technical success rate of EUS-HGS with the intra-conduit release method was significantly higher in comparison with the conventional method. Additionally, the rate of early adverse events was significantly lower than that for the conventional method. The intra-conduit release method during EUS-HGS is useful for a stable procedure that avoids early adverse events.

Utility of Endoscopic Ultrasound-Guided Hepaticogastrostomy with Antegrade Stenting for Malignant Biliary Obstruction after Failed Endoscopic Retrograde Cholangiopancreatography

Background: Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is a well-recognized alternative BD method after unsuccessful endoscopic transpapillary drainage. EUS-guided hepaticogastrostomy (HGS) with antegrade stenting (AGS) was recently applied to the treatment of malignant obstructive jaundice. Objective: To assess the efficacy and safety of HGS combined with AGS for treatment of malignant biliary stricture-induced obstructive jaundice. Design: Retrospective cohort study. Setting: Single academic tertiary care center. Patients: From January 2006 to December 2014, endoscopic retrograde cholangiopancreatography was attempted in patients with obstructive jaundice; it was successful in 641 patients and impossible in 154 patients (postsurgically altered anatomy or duodenal stenosis, n = 101; difficult cannulation, n = 53). In total, 145 patients underwent EUS-guided BD; HGS and HGS with AGS were attempted in 42 patients (Group A, January 2006-August 2011) and 37 patients (Group B, September 2011-December 2014), respectively. Interventions: Under EUS and fluoroscopy guidance, HGS and HGS with AGS were performed via needle puncture, guidewire insertion, puncture-hole dilation, and stent placement. Main Outcome Measurements: Groups A and B were compared in terms of technical success, functional success, adverse event rates, re-intervention rates, patient survival time, and time to stent dysfunction or patient death. The two groups were also compared in a subgroup analysis of only 28 patients who underwent chemotherapy. Results: The technical success rate was significantly higher in Group A than B (97.6 vs. 83.8%, p = 0.03). The functional success rate was comparable between the two groups (90.2 vs. 90.3%), although the rate of adverse events was significantly higher in Group A than B (26.1 vs. 10.8%, p = 0.03). The re-intervention rate tended to be higher in Group A than B (16.7 vs. 8.1%, p = 0.25). Groups A and B did not differ significantly in terms of median overall patient survival (75 vs. 61 days, p = 0.70) or median time to stent dysfunction or patient death (68 vs. 63 days, p = 0.08). Among patients who underwent chemotherapy, there was no difference in overall patient survival time between the two groups (121 vs. 157 days, p = 0.08), although time to stent dysfunction or patient death was significantly shorter in Group A than B (71 vs. 95 days, p = 0.02). Conclusion: Although the technical success rate of HGS with AGS was lower than that of HGS, HGS with AGS was superior to HGS in terms of adverse event rate and stent patency in patients receiving chemotherapy.

Temporary EUS-Guided Hepaticogastrostomy With Electrohydraulic Shockwave Lithotripsy for Management of Altered Anatomy Choledocholithiasis: 2017 Presidential Poster Award

ERCP is challenging in patients with gastric bypass due to altered anatomy. We report a case of symptomatic choledocholithiasis requiring temporary placement of EUS-guided hepaticogastrostomy with a fully covered metal stent and electrohydraulic lithotripsy. This is a 71-year-old female with a history of multiple abdominal surgeries, including Roux-en-Y gastric bypass with Fobi pouch, appendectomy, cholecystectomy, and adhesiolysis who presented with 4 months right upper quadrant abdominal pain and a 1 week hx of jaundice. MRCP revealed intra and extrahepatic ductal dilatation with a 1.1cm obstructing stone in a tortuous CBD. A double balloon enteroscopy assisted ERCP was considered but initial endoscopy revealed a stricture at the GJ anastomosis thought to be related to complications from the fobi pouch. Given the complex anatomy, surgery was consulted to coordinate a laparoscopic-assisted ERCP. However, due to her extensive surgical history and multiple repeated open abdominal surgeries, they strongly advocated for a non-surgical approach. Interventional radiology was then consulted for a percutaneous approach, but explained that they would require multiple procedures for percutaneous tract dilation before the point that stone extraction could be attempted. As a result, an EUS guided approach was performed via creation of a hepaticogastrostomy. The procedure was performed by puncturing a dilated radical of the left intrahepatic system with a 19G FNA needle. A 0.035mm guidewire was passed antegrade down into the tortuous bile duct. A 6mm balloon catheter was passed into the bile duct and used to dilate the tract. A 10mmx8cm fully covered metal biliary stent was placed from the gastric pouch to the intrahepatic ducts with confirmation made with cholangiogram. A pediatric gastroscope was then passed through the stent and eventually into the distal CBD where the stone was seen. Under direct visualization saline assisted electrohydraulic shockwave lithotripsy was performed to fragment the stone. The stone pieces were pushed and flushed through the ampulla. Two months later, patient underwent repeat EGD. The stent was subsequently removed without any complications and today she continues to do well. This case illustrates that lithotripsy through a temporarily placed EUS-guided hepaticogastrostomy may be safe and effective approach for altered anatomy patients who cannot undergo more traditional approaches for management of complex choledocholithiasis.Figure: MRCP Showing 10.4mm CBD Stone.Figure. CBD: Stone Before Lithotripsy.Figure. CBD: Stone After Lithotripsy.

Rescue antegrade diathermic dilation of hyperplastic tissue at partially covered metallic stent after EUS-guided hepaticogastrostomy

Rescue antegrade diathermic dilation of hyperplastic tissue at partially covered metallic stent after EUS-guided hepaticogastrostomy

Stent migration into the abdominal cavity after EUS-guided hepaticogastrostomy

Stent migration into the abdominal cavity after EUS-guided hepaticogastrostomy

Advanced endoscopic ultrasound-guided biliogastric anastomosis and interventions

Background:Endoscopic ultrasound (EUS)-guided biliary drainages are increasingly performed in patients with failed endoscopic retrograde cholangiopancreatography. Common approaches for transmural drainage include choledochoduodenostomy and hepaticogastrostomy (HGS). In this video, we describe three patients with difficult EUS-biliogastric anastomosis and advanced interventions through the established anastomosis.Case Report:Case 1 describes a case in which a choledochogastric anastomosis was performed. A 74-year-old female presented with upper gastrointestinal bleeding with failed endoscopic hemostasis requiring surgical plication of the bleeder, closure of the pylorus and gastrojejunostomy due to a locally advanced pancreatic cancer. She then developed biliary obstruction. A EUS-guided choledochogastrostomy was then performed with a forward-viewing echoendoscope. Case 2 describes a EUS-guided salvage of a misdeployed HGS stent. EUS-guided HGS was performed in a patient with unresectable gastric cancer with pyloric obstruction. During deployment, the proximal end of the stent was deployed in to the peritoneal cavity with loss of guidewire. EUS-guided HGS was then performed to the misdeployed stent. Case 3 describes a patient with 2-staged endoscopic recanalization of a stenosed surgical hepaticojejunostomy for benign distal biliary stricture via a EUS-guided HGS. In the first stage, a EUS-guided HGS was performed through the left intrahepatic duct. The video describes the second stage of the procedure where endoscopic recanalization of the surgical hepaticojejunostomy was performed a few months later.Conclusion:Advanced biliogastric anastomoses and interventions were feasible and successfully avoided surgical interventions in these patients.

Endoscopic ultrasound-guided biliary drainage: Experience from a tertiary center

Background and Objectives:Endoscopic retrograde cholangiopancreatography (ERCP) and palliative biliary stenting are an established therapy for malignant biliary obstruction that is unsuitable for curative surgery. In ERCP failure, EUS-guided biliary drainage (EUS-BD) procedures are evolving alternative endoscopic techniques.Methods:This was a retrospective analysis of patients who underwent EUS-BD.Results:There were 16 patients who underwent EUS-BD in the last 5 years. Male to female ratio was 9:7. Mean age was 63.56 years. Seven patients had carcinoma pancreas; six had periampullary carcinoma and one patient each had duodenal carcinoma, carcinoma colon with infiltration, and hepatocellular carcinoma with hepatic duct stricture. Indication for EUS-BD was inaccessible ampulla in ten, unidentified ampulla in one, failed biliary cannulation in four, and proximal migration of biliary plastic stent in one. Fifteen (93.75%) underwent EUS-guided choledochoduodenostomy (EUS-CDS), while one had EUS-guided hepaticogastrostomy (EUS-HGS). Covered biliary self-expandable metallic stent was used for EUS-CDS and Giobor biliary stent for EUS-HGS. The procedure was technically successful in all. There were no major immediate postprocedure complications. There was significant symptomatic and biochemical improvement in all. Thirty-day survival was 100%.Conclusion:In malignant biliary obstruction with failed ERCP, EUS-guided bile duct drainage has a high potential as an alternative biliary decompression procedure.

Safety and effectiveness of a long, partially covered metal stent for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction.

Background and study aims: Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is potentially complicated by bile leak and stent migration. The aim of this study was to evaluate the safety and effectiveness of a long (≥ 10 cm), partially covered metal stent (LP-CMS) for EUS-guided hepaticogastrostomy (EUS-HGS) for malignant biliary obstruction. Both the stent length and the uncovered portion at the proximal end of the LP-CMS are designed to prevent stent migration. Patients and methods: A total of 33 patients undergoing EUS-HGS using an LP-CMS in four centers were retrospectively studied. Technical and clinical success, adverse events, and recurrent biliary obstruction were evaluated. Results: Gastric outlet obstruction (76 %) and surgically altered anatomy (15 %) were two major reasons for EUS-HGS. The technical and clinical success rates were 100 %. The median intragastric stent length was 54 mm. The adverse event rate was 9 %. No stent migration was observed. Recurrent biliary obstruction developed in 24 %, with a median cumulative time to recurrence of 8.5 months. Conclusions: EUS-HGS using an LP-CMS for unresectable malignant biliary obstruction was safe and effective.

Long-term outcomes of a newly developed hybrid metal stent for EUS-guided biliary drainage (with videos)

Although fully covered self-expandable metal stents (FCSEMSs) have been commonly used for EUS-guided biliary drainage (EUS-BD), FCSEMS migration is a main limitation of this procedure. In the present study we evaluated the technical and clinical success rates, adverse events, and long-term outcomes of a newly developed hybrid stent that has been customized for EUS-BD. From September 2011 to May 2015, 54 consecutive patients with biliary obstruction were enrolled in this prospective, observational study. These patients were candidates for alternative BD techniques because of failed ERCP. The hybrid metal stent used for EUS-BD in this study was partially covered, had anchoring flaps, and is commercially available in Korea. EUS-guided hepaticogastrostomy (EUS-HGS) was performed in 21 patients and EUS-guided choledochoduodenostomy (EUS-CDS) in 33 patients. The technical and clinical success rates of EUS-BD were 100% (54/54) and 94.4% (51/54), respectively. Immediate adverse events developed after EUS-BD in 9 patients (16.6%; cholangitis in 3, bleeding in 2, self-limited pneumoperitoneum in 3, and abdominal pain in 1). Proximal or distal stent migration was not observed during the follow-up period (median, 148.5 days; IQR, 79.7-244), and the mean stent patency duration was 166.3 days and 329.1 days in the EUS-HGS and EUS-CDS groups, respectively. EUS-BD with the hybrid metal stent is technically feasible and can effectively treat biliary obstruction after failed ERCP. EUS-BD with the hybrid metal stent can reduce stent-related adverse events, especially stent migration.

ERCP through a gastrojejunal lumen-apposing stent.

Figure 2. Fluoroscopic view showing passage of guidewire into the distal duodenum. We present a case of an 84-year-old man who had received a diagnosis of pancreatic head adenocarcinoma 2 years earlier. At that time, he had received bile and pancreatic duct stents with resolution of jaundice and improvement in diarrhea. Over the past month, the patient started experiencing epigastric pain, nausea, and vomiting. Cross-sectional imaging demonstrated no significant change in pancreatic mass size, with intact stents and stable pneumobilia. An upper endoscopy was then performed, demonstrating narrowing of the second portion of the duodenum with inability of the endoscope to traverse this segment. Contrast medium was injected into the duodenal bulb and showed evidence of severe narrowing of the second portion of the duodenum (Fig. 1). A long ERCP guidewire was advanced through the upper endoscope past the duodenal narrowing and looped in the distal duodenum (Fig. 2). The endoscope was then withdrawn while the guidewire was maintained in place. A dilation balloon was advanced over the guidewire into the distal duodenum and inflated to 18 mm (Fig. 3). A linear echoendoscope was then advanced into the stomach. The dilated balloon was identified and punctured with a 19-gauge needle and immediate dissipation of contrast medium into the small intestine was observed (Fig. 4). Another guidewire was advanced through the 19-gauge needle into the small intestine. A Boston-Scientific (Marlborough, Mass) electrocautery-enhanced Axios stent was then deployed over the guidewire into the lumen of the small intestine (Fig. 5). The stent was then dilated with a 13.5-mm dilation balloon (Fig. 6). The final endoscopic and fluoroscopic appearance appeared satisfactory. The patient did well after the procedure, with resolution of symptoms, and was discharged the next day after tolerating a regular diet. However, the patient presented about 2 weeks later with right upper-quadrant pain, fever, and an increase in bilirubin from 0.4 to 2.6 mg/dL. A transabdominal US showed worsening intrahepatic biliary dilatation. Intravenous antibiotics were started, with improvement in symptoms but persistence of laboratory abnormalities. We then discussed with the patient the options of percutaneous drainage, EUS-guided hepaticogastrostomy, or an attempt at exchanging the stent through the newly placed Axios stent. The patient opted for an endoscopic

Su1282 Optimal biliary access point for EUS-guided hepaticogastrostomy with transmural stenting

Su1282 Optimal biliary access point for EUS-guided hepaticogastrostomy with transmural stenting

Visualization and removal of intrahepatic bile duct stones through EUS-guided hepaticogastrostomy

Visualization and removal of intrahepatic bile duct stones through EUS-guided hepaticogastrostomy

Technical tips for endoscopic ultrasound-guided hepaticogastrostomy

Interventional procedures using endoscopic ultrasound (EUS) have recently been developed. For biliary drainage, EUS-guided trans-luminal drainage has been reported. In this procedure, the transduodenal approach for extrahepatic bile ducts is called EUS-guided choledochoduodenostomy, and the transgastric approach for intrahepatic bile ducts is called EUS-guided hepaticogastrostomy (EUS-HGS). These procedures have several effects, such as internal drainage and avoiding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and they are indicated for an inaccessible ampulla of Vater due to duodenal obstruction or surgical anatomy. EUS-HGS has particularly wide indications and clinical impact as an alternative biliary drainage method. In this procedure, it is necessary to dilate the fistula, and several devices and approaches have been reported. Stent selection is also important. In previous reports, the overall technical success rate was 82% (221/270), the clinical success rate was 97% (218/225), and the overall adverse event rate for EUS-HGS was 23% (62/270). Adverse events of EUS-biliary drainage are still high compared with ERCP or PTCD. EUS-HGS should continue to be performed by experienced endoscopists who can use various strategies when adverse events occur.

Endoscopic ultrasonography-guided biliary drainage: Who, when, which, and how?

Both endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (EUS-CDS) and EUS-guided hepaticogastrostomy (EUS-HGS) are relatively well established as alternatives to percutaneous transhepatic biliary drainage (PTBD). Both EUS-CDS and EUS-HGS have high technical and clinical success rates (more than 90%) in high-volume centers. Complications for both procedures remain high at 10%-30%. Procedures performed by endoscopists who have done fewer than 20 cases sometimes result in severe or fatal complications. When learning EUS-guided biliary drainage (EUS-BD), we recommend a mentor's supervision during at least the first 20 cases. For inoperable malignant lower biliary obstruction, a skillful endoscopist should perform EUS-BD before EUS-guided rendezvous technique (EUS-RV) and PTBD. We should be select EUS-BD for patients having altered anatomy from malignant tumors before balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography, EUS-RV, and PTBD. If both EUS-CDS and EUS-HGS are available, we should select EUS-CDS, according to published data. EUS-BD will potentially become a first-line biliary drainage procedure in the near future.

Natural orifice transluminal endoscopic surgery to salvage a migrated stent during EUS-guided hepaticogastrostomy

Natural orifice transluminal endoscopic surgery to salvage a migrated stent during EUS-guided hepaticogastrostomy