Endoscopic ultrasound-guided hepaticogastrostomy with antegrade and bridging stenting for diffusely extending cholangiocarcinoma

An 81-year-old female patient with jaundice and a total bilirubin level of 25 mg/dL was diagnosed with distal cholangiocarcinoma extending bilaterally to the intrahepatic bile ducts ( Fig. 1 ). Although endoscopic retrograde cholangiopancreatography was attempted, the major papilla could not be approached due to tumor infiltration of the duodenum ( Fig. 2 ). Thus, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed to achieve biliary drainage ( Video 1 ), where the B3 branch of the left intrahepatic bile duct was punctured from the stomach ( Fig. 3 a and b ). For antegrade stenting, an uncovered self-expandable metal stent (SEMS) was deployed via the major papilla from the common bile duct to the left hepatic duct ( Fig. 3 c ). Next, using the partial stent-in-stent method, another uncovered SEMS was deployed from the right anterior biliary branch to the left hepatic duct to bridge bilateral biliary branches ( Fig. 3 d ). Finally, a partially covered SEMS was deployed from the B3 branch of the left intrahepatic bile duct into the hepaticogastrostomy fistula to sustain a re-intervention route in the case of stent failure ( Fig. 3 e and Fig. 4 ). No procedure-related adverse events occurred. Within 3 days, the total bilirubin level decreased to less than one-third the initial measurement.

Fig. 1.

a Enhanced computed tomography showing distal bile duct obstruction caused by cholangiocarcinoma (arrow) and subsequent thickening of the bile duct wall extending bilaterally to the secondary bile duct branches (arrow heads). b Magnetic resonance cholangiopancreatography showing bilateral narrowing of the bile ducts up to their secondary branches (arrow heads) and dilation of peripheral intrahepatic biliary branches.

Fig. 2.

An endoscopic view showing tumor infiltration into the descending part of duodenum.

Fig. 3.

Fluoroscopic images of endoscopic ultrasound-guided hepaticogastrostomy. a The insertion of a guidewire through the major papilla into the duodenum via the hepaticogastrostomy route. b Another guidewire inserted into the right anterior biliary branch. c An uncovered self-expandable metal stent (SEMS) deployed from the common bile duct to the left hepatic duct via the major papilla. d Another uncovered SEMS deployed from the right anterior biliary branch to the left hepatic duct using the partial stent-in-stent method. e A partially covered SEMS deployed from the B3 branch of the left intrahepatic bile duct into the hepaticogastrostomy fistula. SEMS, self-expandable metal stent.

Fig. 4.

An endoscopic view showing a partially covered SEMS deployed into the hepaticogastrostomy fistula. SEMS, self-expandable metal stent.

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Endoscopic ultrasound-guided hepaticogastrostomy with antegrade and bridging stenting was performed to achieve biliary drainage in a patient with diffusely extending cholangiocarcinoma that had infiltrated the duodenum.

Video 1

When the transpapillary approach to the malignant biliary stricture is challenging, endoscopic ultrasound-guided biliary drainage is preferred over a percutaneous transhepatic biliary drainage because of better clinical efficacy and non-invasiveness ^{1 2} .The time to recurrent biliary obstruction is longer in EUS-HGS with antegrade stenting for malignant distal biliary obstruction than that without it ^{3 4} .Furthermore, for malignant perihilar biliary strictures, bilateral stenting results in longer stent patency than unilateral stenting ⁵ . In this case, where the stricture extended to bilateral biliary branches, additional bridging stenting resulted in successful biliary drainage ( Fig. 5 ). Multiple biliary stenting via EUS-HGS can be effective and safe for diffuse bile duct strictures.

Fig. 5.

Computed tomography showing three SEMSs used in antegrade and bridging stenting, along with hepaticogastrostomy. SEMSs, self-expandable metal stents.

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