Reintervention using cholangioscopy for metallic stent obstruction following endoscopic ultrasound-guided hepaticogastrostomy

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a valuable alternative for patients for whom endoscopic retrograde cholangiopancreatography (ERCP) is not feasible. However, recurrent biliary obstruction occurs in approximately 19.1–33% of cases, often necessitating reintervention ^{1 2} . Herein, we report a case of successful reintervention using peroral cholangioscopy to treat biliary obstruction caused by tissue hyperplasia at the uncovered portion of a self-expandable metallic stent (SEMS) placed during EUS-HGS ( Video 1 ).

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Reintervention using cholangioscopy for metallic stent obstruction following endoscopic ultrasound-guided hepaticogastrostomy.

Video 1

A 75-year-old man who underwent EUS-HGS for duodenal papillary carcinoma ( Fig. 1 ) was diagnosed with acute cholangitis due to stent dysfunction. Reintervention was attempted using the previously created endosonographic route.

Fig. 1.

a Computed tomography (CT) image showing duodenal papillary carcinoma. b Magnetic resonance cholangiopancreatography (MRCP) showing a distal bile duct stricture. c Gastroscopy showing duodenal stenosis due to duodenal papillary cancer. d A partially covered self-expandable metallic stent was placed on the B3 branch.

A dual-channel endoscope (GIF-2TQ260M, Olympus, Japan) was used to trim the SEMS. The SEMS was grasped with forceps and trimmed via a secondary channel using argon plasma coagulation ( Fig. 2 a ). Subsequently, contrast imaging was performed using a duodenoscope (TJF-Q290V, Olympus, Japan), confirming complete stent obstruction ( Fig. 2 b, c ). Despite multiple attempts, a 0.025-in. angle-type guidewire could not be passed through the obstructed site ( Fig. 2 d ).

Fig. 2.

Reintervention using an endoscopic retrograde cholangiopancreatography (ERCP) catheter. a The SEMS trimmed using argon plasma coagulation. b The ERCP catheter is inserted into the SEMS. c Cholangiography confirmed biliary obstruction. d Attempts at guidewire passage were unsuccessful.

Peroral cholangioscopy (Spyglass DS, Boston Scientific, Marlborough, USA) was advanced through the SEMS, revealing complete obstruction of the uncovered segment by hyperplastic tissue ( Fig. 3 a, b ). A 0.025-in. straight-type guidewire was successfully navigated into the common bile duct under direct cholangioscopic visualization ( Fig. 4 a, b ). Balloon dilation of the obstructed site was then performed, followed by the placement of a plastic stent across the obstruction ( Fig. 4 c, d ).

Fig. 3.

a A cholangioscope introduced into the SEMS. b Uncovered segment of the SEMS is completely occluded by hyperplastic tissue.

Fig. 4.

Reintervention using peroral cholangioscopy. a, b Guidewire passage was successfully performed under direct cholangioscopic visualization. c Balloon dilation at the obstruction site. d Plastic stent placed in the bile duct.

Peroral cholangioscopy-guided reintervention for SEMS obstruction after EUS-HGS can be an effective approach, particularly in cases where conventional guidewire passage is challenging.

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