Acronyms and abbreviations
Video 1 A SpyGlass DS direct cholangioscopic view showing holmium laser ablation (0.9–1.0 J, 5 Hz) applied to hyperplastic tissue at the uncovered portion of the SpringStopper stent.
- EUS-HGS
EUS-guided hepaticogastrostomy
- PCSEMS
partially covered self-expandable metal stent
- RBO
recurrent biliary obstruction
- RFA
radiofrequency ablation
Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an established biliary drainage technique when transpapillary biliary access is insufficient. Recurrent biliary obstruction (RBO) after EUS-HGS is not uncommon; Nakai et al reported hyperplasia at the uncovered portion as the major cause after long partially covered metal stent placement. 1 Reintervention strategies include radiofrequency ablation (RFA) 2 , piercing techniques 3 , and cholangioscopy-guided laser ablation. 4 5 However, laser ablation has not been applied to hyperplasia via the EUS-HGS route. A 53-year-old woman underwent EUS-HGS targeting B3 with simultaneous endoscopic retrograde cholangiopancreatography for the right hepatic duct. An 8-mm, 10-cm SpringStopper stent (Taewoong Medical, Gyeonggi-do, Korea) was placed. Three months later, hyperplasia-related cholangitis developed, and an 8-mm, 6-cm Zilver stent (Cook Medical, Bloomington, IN, USA) was added within the SpringStopper. Four months thereafter, cholangitis recurred. Coronal computed tomography showed intrahepatic bile duct dilatation proximal to the stent, suggesting obstruction ( Fig. 1 ). Cholangiography confirmed a stricture at the hepatic side ( Fig. 2 ). A guidewire was advanced through the hyperplastic tissue into the proximal bile duct. SpyGlass DS (Boston Scientific, Marlborough, MA, USA) was introduced, and holmium laser ablation was performed under direct cholangioscopic vision ( Video 1 ). Energy was initiated at 0.9 J/5 Hz and increased to 1.0 J until luminal breakthrough. Dilation was performed using an 8-mm REN balloon catheter (Kaneka, Osaka, Japan). Post-ablation cholangiography showed no residual filling defects ( Fig. 3 ). Cholangitis resolved without adverse events, with no RBO at 2 months. This case demonstrates holmium laser ablation for benign hyperplastic RBO after EUS-HGS. Because RFA provides circumferential thermal ablation and may be less suitable for selectively fenestrating a membranous hyperplastic stricture, cholangioscopy-guided laser ablation may offer a more controlled approach for focal recanalization. However, the procedure was time consuming (100 min), and careful patient selection is warranted.
Fig. 1.
A coronal CT image showing intrahepatic bile duct dilat`ation proximal to the metal stent, suggesting obstruction due to mucosal hyperplasia.
Fig. 2.
A fluoroscopic cholangiogram before laser ablation demonstrating a stricture at the hepatic side of the SpringStopper stent (arrow).
Fig. 3.
A fluoroscopic cholangiogram after laser ablation showing no residual filling defects and improved bile flow.
Endoscopy_UCTN_Code_TTT_1AR_2AL
Footnotes
Conflict of Interest Author H.I. was supported by research grants from Boston Scientific Japan and FUJIFILM Corporation. The funding source has no role in the design, practice, or analysis of this study. All other authors have no conflict of interest.
Contributorsʼ Statement Tomoya Takahashi: conceptualization, formal analysis, methodology, validation, visualization, and writing – original draft. Ko Tomishima: conceptualization, methodology, project administration, validation, and writing – review and editing. Yusuke Takasaki: data curation, investigation, and resources. Yoko Iwabe: data curation, investigation, and resources. Yusuke Yamaguchi: data curation, investigation, and resources. Daishi Kabemura: data curation, investigation, and resources. Hiroyuki Isayama: supervision and writing – review and editing.
References
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