An 85-year-old woman underwent right hepatectomy with choledochojejunostomy because of a diagnosis of hepatocellular carcinoma 1 year earlier. She was admitted to our hospital because of frequent cholangitis. On CT, intrahepatic bile duct dilatation and stones were seen. She had dementia, so a percutaneous approach was contraindicated because of the risk of her removing the tube. A surgical approach was also a contraindication because of her older age and dementia. A transgastric approach was therefore selected. First, EUS-guided hepaticogastrostomy (HGS) was performed, during which we determined whether the cholangiocarcinoma was complicated, and we attempted to remove the stones (Video 1, available online at www.giejournal.org). An ERCP catheter was inserted into the bile duct through an EUS-HGS stent, and contrast medium was injected. Cholangiography showed multiple defects in the left intrahepatic bile duct (Fig. 1A). The cholangioscope was then inserted into the intrahepatic bile duct through the EUS-HGS stent (Fig. 1B). Although multiple stones were seen, the mucosa of the intrahepatic bile duct was clear and smooth. Next, a basket catheter was inserted, and the stones were successfully removed (Fig. 1C). There were no adverse events associated with this procedure. If a patient with an intrahepatic bile duct stone cannot be treated by a surgical or percutaneous approach because of dementia or other factors, our technique has clinical impact.
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Published online: March 25, 2016Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Copyright © 2016 by the American Society for Gastrointestinal Endoscopy