Piercing technique for mucosal hyperplasia at an uncovered part of a partially covered stent after endoscopic ultrasound-guided hepaticogastrostomy

A partially covered self-expandable metal stent (PCSEMS) is preferred in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) to prevent stent dislocation and branch duct occlusion ^{1 2} . A PCSEMS with a 10-mm uncovered part on the proximal end (Modified Giobor Stent; Taewoong Medical, Seoul) ( Fig. 1 a) has been used frequently ^{2 3} ; however, tissue hyperplasia occurs around the uncovered part, leading to recurrent biliary obstruction (RBO) ^{2 3} . RBO due to hyperplasia is sometimes hardened with abundant fibrosis, resulting in failed guidewire passage during endoscopic reintervention ^{3 4} . Here, we present a novel technique to regain biliary access after EUS-HGS with subsequent hyperplasia with the uncovered portion of the PCSEMS.

Fig. 1.

a A partially covered self-expandable metal stent (Modified Giobor Stent; Taewoong Medical, Seoul, South Korea) made of braided nitinol wire partially covered by a silicone membrane. The proximal end has a 10-mm uncovered portion. b Endoscopic view of the partially covered metal stent in the gastric lumen after endoscopic ultrasound-guided hepaticogastrostomy.

A 67-year-old male with a history of distal gastrectomy with Roux-en-Y reconstruction was admitted due to jaundice. The patient had undergone EUS-HGS with the PCSEMS for biliary obstruction due to lymph node metastasis 8 months before admission ( Fig. 1 b). To relieve jaundice, reintervention via the distal end of the PCSEMS was performed. A cannulation catheter was inserted from the distal end of the PCSEMS, but a 0.035-inch guidewire (Jagwire; Boston Scientific, Natick, Massachusetts, United States) could not be advanced beyond the PCSEMS. The uncovered part of the PCSEMS was not imaged by contrast medium injection, indicating a complete RBO due to hyperplasia ( Fig. 2 ). Next, a stone extraction balloon was inflated inside the PCSEMS to allow passage of the guidewire through the center of the PCSEMS ( Fig. 3 ). However, the hyperplasia was too stiff. Finally, a “piercing technique” using the stiff back end of the guidewire ⁵ was performed, which allowed the guidewire to smoothly advance the stricture ( Fig. 4 , Video 1 ). After dilating the uncovered part with an 8-mm balloon dilator, a dedicated plastic stent was successfully deployed through the PCSEMS ( Fig. 5 ). The patient’s jaundice resolved after endoscopic revision and was discharged 6 days after admission.

Fig. 2.

The uncovered part of the partially covered metal tent was not imaged by contrast medium injection (arrowheads), indicating a complete recurrent biliary obstruction due to hyperplasia.

Fig. 3.

A stone extraction balloon (Fusion Extraction Balloon; Cook Medical, Bloomington, Indiana, United States) was inflated inside the partially covered metal stent to allow passage of the guidewire through the center of the stent ( a fluoroscopic view, b. diagram).

Fig. 4.

In a “piercing technique,” the stiff back end of a 0.035-inch guidewire (Jagwire; Boston Scientific, Natick, Massachusetts, United States) was used, which enabled the smooth advancement of the guidewire beyond the hyperplasia at the proximal end of the stent ( a fluoroscopic view, b diagram).

Fig. 5.

A dedicated 7F × 14-cm plastic stent (TYPE-IT Stent; Gadelius Medical, Tokyo, Japan) was successfully deployed through the existing partially covered metal stent ( a fluoroscopic view, b endoscopic view).

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Endoscopic reintervention using a “piercing technique” for mucosal hyperplasia after endoscopic ultrasound-guided hepaticogastrostomy.

Video 1