Endoscopic ultrasound-guided hepaticogastrostomy using a 6-F cystotome and 12-cm covered metal stent

Loop technique for guidewire manipulation during endoscopic ultrasound-guided hepaticogastrostomy

Background and Aim

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is widely used in the management of biliary obstructions; however, literature on guidewire manipulation is lacking. This study aimed to assess the utility and optimal conditions of the loop technique for guidewire manipulation during EUS-HGS.

Methods

Consecutive patients who underwent EUS-HGS between April 2015 and January 2022 were included in this study. Patient characteristics and procedural details were retrospectively analyzed. Guidewire manipulations were classified as conventional technique or loop technique, based on the shape of the guidewire tip.

Results

A total of 52 patients (Median age: 73 years, 38 male and 14 female) underwent EUS-HGS. The median guidewire insertion time was 49 s and the median overall procedure time was 20.5 min. The initial guidewire direction was toward the peripheral side in 23 patients (44%). Technical success rate of the EUS-HGS was 100%. Twenty patients (38%) underwent the procedure using the loop technique and 32 (62%) with the conventional technique. In the logistic regression analysis, an angle between the bile duct and needle of >70° was independently associated with use of the loop technique (OR 9.84; 95% CI: 2.24-43.13; P <0.01).

Conclusion

This study revealed the utility of the loop technique in EUS-HGS. This technique is recommended if the bile duct is punctured at an angle >70°.

Endoscopic Ultrasound-Guided Biliary Drainage in Two Patients with Difficult Biliary Access

INTRODUCTION

Endoscopic retrograde cholangiopancreatography is the method of choice for biliary drainage, although in some cases standard biliary access is difficult or even impossible. Endoscopic ultrasound (EUS)-guided endoluminal procedures are an alternative in these cases, although experience with these techniques is still limited.

CLINICAL CASE

We present two cases of successful EUS-guided biliary drainage. In the first case, a hepaticogastrostomy was performed in a patient with stage IV gastric adenocarcinoma with obstructive jaundice due to compression of the hilum, where malignant gastric stenosis and previous palliative gastrojejunostomy precluded access to the second part of the duodenum. In the second case, a patient with a pancreatic head adenocarcinoma with duodenal invasion that precluded major papillae identification was submitted to a choledochoduodenostomy. Both procedures occurred without immediate or delayed adverse events, with technical and clinical success.

DISCUSSION

Although experience with EUS-guided biliary drainage is still limited, its efficacy and safety is favorable when compared with percutaneous and surgical drainage, and should be considered an alternative to these techniques where sufficient expertise exists.

Relationship Between the Intraperitoneal Stent Length in Endoscopic Ultrasound-Guided Hepaticogastrostomy and Surgically Altered Upper Gastrointestinal Anatomy in Patients With Malignant Biliary Obstruction

Background

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is associated with a relatively high proportion of adverse events, and this is attributable to the lack of standardized protocols and specialized equipment. Although the outcomes of EUS-HGS may differ between patients with and those without surgically altered upper gastrointestinal anatomy, there have been no reports on this topic. The present study aimed to evaluate the efficacy and safety of EUS-HGS using our standardized method and to compare the outcomes between patients with and those without surgically altered upper gastrointestinal anatomy.

Methods

In EUS-HGS, we used a long partially covered metal stent, and we kept the gastric wall pressed with the scope tip until the stent was deployed more than 1 cm inside the working channel of the scope to minimize free space between the liver and gastric wall (the intraperitoneal stent length). A total of 12 patients who underwent EUS-HGS using our method were retrospectively studied. Procedural success and adverse events were evaluated, and the outcomes of EUS-HGS were compared between six patients with and six without surgically altered upper gastrointestinal anatomy.

Results

The procedural success rate was 100%. Additionally, stent migration or dislocation was not noted in any of the patients. The intraperitoneal stent length was significantly greater in patients without surgically altered upper gastrointestinal anatomy than in those with surgically altered upper gastrointestinal anatomy (19.8 mm vs. 11.6 mm; 95% confidence interval, 2.185 - 14.147; P = 0.012).

Conclusions

EUS-HGS using our method was safe. Our findings suggested that special attention should be paid to stent migration or dislocation in patients without surgically altered upper gastrointestinal anatomy.

Endoscopic management of difficult benign biliary and pancreatic strictures using a wire-guided cystotome: experience with 25 cases

BACKGROUND AND STUDY AIMS

Endoscopic management using standard accessories is the preferred modality for treatment of benign biliary strictures. However, with difficult strictures, there is frequently failure of endoscopic therapy. We are reporting our experience regarding use of a standard diathermic dilator (cystotome) to aid in stricture dilatation and stent placement in patients with difficult strictures.

PATIENTS AND METHODS

Data were analyzed from January 2014 to January 2017 at a single tertiary care center in North India. Total 25 patients were included.

RESULTS

The mean age was 45 years (varying from 38 - 55 years). Of the 25 patients with difficult strictures, 14 (56 %) were male and 11 (44 %) were female. Further, of these, 19 had biliary and 6 had pancreatic strictures. The average time of diathermic current application was 3.5 seconds (ranging 3 - 5 seconds). Technical and clinical success were achieved in 100 % of cases. None of the patients had any procedure-related (early or delayed) major complications.

CONCLUSION

The cystotome is an extremely safe and useful accessory in benign biliary and pancreatic strictures, whereas conventional methods to negotiate stricture have failed.