EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos)

Background

Percutaneous transhepatic biliary drainage (PTBD) may be the last resort for an occluded biliary metal stent when the ERCP was unsuccessful.

Objective

Because an EUS-guided biliary drainage has been proposed as an effective alternative for PTBD after a failed ERCP, we conducted this study to determine the feasibility and usefulness of an EUS-guided hepaticogastrostomy (EUS-HG) with a fully covered self-expandable metal stent (FCSEMS) for an occluded biliary metal stent after a failed ERCP.

Design

A case study.

Setting

A tertiary referral center.

Patients and Interventions

Five patients who had an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion and for whom reinterventional ERCP was unsuccessful underwent an EUS-HG with an FCSEMS for alternative PTBD.

Main Outcome Measurements

Technical and functional success, procedural complications, reinterventional rate after EUS-HG with an FCSEMS, and short-term stent patency.

Results

In all 5 patients, an EUS-HG with an FCSEMS was technically successful. No procedural complications, such as bile peritonitis, cholangitis, and pneumoperitoneum, were observed. Functional success was also 100% (5/5). During the follow-up period (median 152 days, range 64-184 days), no late complications, such as stent migration and occlusion, were observed. Thus, no biliary reintervention was performed during the follow-up period.

Limitations

A small series of patients without a control group.

Conclusions

The EUS-HG with an FCSEMS may be feasible, effective, and an alternative PTBD for an occluded biliary metal stent after a failed ERCP.

Abbreviations: EUS-BD, EUS-guided biliary drainage, EUS-HG, EUS-guided hepaticogastrostomy, FCSEMS, fully covered self-expandable metal stent, PTBD, percutaneous transhepatic biliary drainage, SEMS, self-expandable metal stent