EUS-guided biliary drainage for internalization of percutaneous transhepatic biliary drainage

Abstract

The interventional potential of EUS continues to evolve, most notably in techniques for EUS-guided biliary drainage (EUS-BD). In skilled hands, EUS-BD can provide access to the biliary tree in patients with an inaccessible papilla or surgically altered luminal anatomy, or in those with biliary obstruction and prior incomplete biliary drainage after ERCP. Emerging data suggest that EUS-BD can be performed to provide internalization of biliary drainage in patients who have previously undergone percutaneous transhepatic biliary drainage (PTBD). A 59-year-old man with stage IV colorectal cancer with extensive metastatic disease to his liver and right lung underwent EUS-guided internalization of his PTBD by use of an EUS-guided hepaticogastrostomy (EUS-HGS) approach. After diagnosis, he underwent sigmoidectomy and subsequently a right hepatectomy. More recently, he experienced a high-grade biliary obstruction at the level of the left main hepatic duct. The patient underwent PTBD for decompression. Two attempts at internalization of biliary drainage with ERCP were unsuccessful. He was then referred for EUS-HGS to internalize his percutaneous biliary drainage catheter (Video 1, available online at www.VideoGIE.org; Fig. 1). Figure 1 A, Injection of water-soluble contrast medium through the percutaneous drain, demonstrating complete obstruction at the left main hepatic duct. B, EUS-guided puncture of a dilated biliary radicle in segment II of the liver. C, Deployment of the distal stent into the peripheral hepatic duct under endosonographic guidance. D, Final fluoroscopic image demonstrating successful hepaticogastrostomy with use of a prototype self-expandable metal stent and double-pigtail plastic stent. E, Final endoscopic image demonstrating successful hepaticogastrostomy with use of a prototype self-expandable metal stent and double-pigtail plastic stent. F, The percutaneous catheter was injected to demonstrate successful internalization of biliary drainage by EUS-guided hepaticogastrostomy. Disclosure Dr Perez-Miranda is a consultant for Boston Scientific, W. L. Gore, and M. I. Tech. All other authors disclosed no financial relationships relevant to this publication.