Transpapillary drainage may be inadequate for malignant hilar biliary obstruction with extensively separated ducts, and endoscopic ultrasound guided biliary drainage (EUS-BD) has been reported as salvage therapy 1 2 3 . 7-Fr slim-delivery self-expandable metal stents (SEMSs) have enabled non-dilation EUS-BD ( 4 5 ; Fig. 1 ). We report jaundice relief using non-dilation EUS-guided hepaticoduodenostomy and hepaticogastrostomy (EUS-HDGS) with a 7-Fr delivery partially covered SEMS system for hepatocellular carcinoma–related hilar obstruction.
Fig. 1.
7-Fr delivery partially covered slim-delivery self-expandable metal stents used in the procedure. a A 0.025-inch guidewire and the 7-Fr delivery catheter (arrow). b The ultra-tapered distal tip measures 0.87 mm (approximately 2.6 Fr).
A 68-year-old man with hepatitis C-related cirrhosis (Child-Pugh score, 11) and moderate ascites exhibited malignant hilar obstruction with separated ducts due to hepatocellular carcinoma. Because the tumor ruptured, emergency transarterial embolization was prioritized ( Fig. 2 ). Endoscopic retrograde cholangiopancreatography was attempted, and although guidewire access was achieved, device advancement, including a catheter, was impossible due to severe stenosis and marked ductal deviation. Therefore, an internal plastic stent (7 Fr, 9 cm) was placed only in the anterior sectoral duct ( Fig. 3 ). However, additional biliary drainage was required due to persistent jaundice, and EUS-HDGS was planned ( Video 1 ).
Fig. 2.
Pre-procedural contrast-enhanced computed tomography. a Intratumoral hemorrhage in hepatocellular carcinoma (arrow). b Malignant hilar biliary obstruction with separate intrahepatic ducts (arrow). c Moderate ascites due to cirrhosis (arrow).
Fig. 3.
Fluoroscopic images during endoscopic retrograde cholangiopancreatography. a Guidewires were advanced into B3 and B5; catheter advancement toward B3 was impeded by sharp angulation (arrow). b The guidewires were advanced into B5 and B6. c Catheter advancement into B6 was not possible (arrow). d An internal plastic stent was placed in the anterior sectoral duct, and the procedure was completed.
EUS-guided hepaticoduodenostomy and hepaticogastrostomy for hilar obstruction with separated ducts. EUS, endoscopic ultrasound.
Video 1
From the duodenal bulb, B6 was punctured using a 19-gauge FNA needle, and a 0.025-inch guidewire was advanced into the intrahepatic duct. After bile aspiration and cholangiography, a partially covered SEMS (8 mm × 12 cm) with a 7-Fr delivery system was deployed without tract dilation ( Fig. 4 a, b ). B3 was similarly accessed from the stomach. A second partially covered SEMS (8 mm × 12 cm) was placed without tract dilation ( Fig. 4 c, d ). Postprocedural computed tomography confirmed appropriate stent positions. No adverse events occurred, and total bilirubin levels decreased by >50% by day 6.
Fig. 4.
Fluoroscopic images during endoscopic ultrasound-guided hepaticoduodenostomy and hepaticogastrostomy. a A 7-Fr delivery catheter was advanced from the duodenal bulb into B6 without tract dilation. b A partially covered SEMS (8 mm × 12 cm) was deployed from B6 to the duodenal bulb. c A 7-Fr delivery catheter was advanced from the stomach into B3 without dilation. d Partially covered SEMSs (8 mm × 12 cm) were deployed from B3 to the stomach. SEMS, self-expandable metal stent.
In patients with advanced cirrhosis and ascites, minimizing tract manipulation is desirable due to concerns regarding bleeding and bile leakage. A 7-Fr delivery system may facilitate non-dilation and multiroute EUS-BD for malignant hilar obstructions with separated ducts.
Endoscopy_UCTN_Code_TTT_1AS_2A
Acknowledgement
We thank the staff of the Department of Gastroenterology, Yokohama City Minato Red Cross Hospital, for their clinical support and assistance with data collection.
Footnotes
Conflict of Interest The authors declare that they have no conflict of interest.
Contributorsʼ Statement Hidenobu Hara: Data curation, Investigation, Writing – original draft, Writing – review & editing. Yoko Henta: Writing – review & editing. Risa Katsumata: Writing – review & editing. Hiroaki Matsumoto: Writing – review & editing. Shiori Ito: Writing – review & editing. Kouhei Yoshino: Writing – review & editing. Shinya Sakita: Writing – review & editing.
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