Name: endoscopic ultrasound-guided biliary drainage: endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction
Uploaded: 2022-03-25T13:00:00
Description: Watch this Scientific Journal Video about Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction at JoVE.com

The authors have no acknowledgments.

The protocol was performed in accordance with the ethical guidelines of the University of Malaya Medical Center. Written consent was obtained, and a detailed explanation of the procedure was provided to the patient. Permission was also granted to produce the video of the procedure for educational purposes.
1. Positioning and sedation
<ol>
	<li>Place the patient in a prone position. Provide moderate sedation using intravenous infusion of Propofol. Ensure the infusion is titra...

The above case description illustrates the possibility of using EUS-HGS as an alternative biliary drainage method in the management of biliary tract malignancies compared to existing methods such as ERCP and PTBD. Among the steps described above, identifying, and accessing the correct intrahepatic duct, guidewire manipulation, and stent deployment are the three main crucial steps in ensuring that the procedure can be performed successfully and safely.
In choosing the ideal liver segment for bi...

Patients with malignant biliary obstruction are often unresectable and advanced at presentation1,2. As a result, palliative endoscopic biliary decompression is often needed in managing these cases3,4,5. According to current recommendations, Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary method of biliary drainage, whenever possible, and if this fails or is contraindicated, Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method6,7,8. However, there are certain complications associated with PTBD, which include septicemia, cholangitis, bleeding, electrolyte lost, leakage, wound infection, local discomfort; these complications are reported to be as high as 53.2%9. The emergence of Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method to address this gap. The principal technique of EUS-BD involves the use of endosonographic imaging to guide access to the biliary system via the gastrointestinal tract to provide therapeutic decompression of an obstructed biliary system.
EUS-BD was first performed in 2001, and since then, this method of biliary drainage has evolved over the years10. Methods of EUS-BD commonly are EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided Anterograde stenting (EUS-AS), and EUS-guided Rendezvous (EUS-RV)11,12. To date, the indications for EUS-BD include patients who have failed ERCP, patients having an inaccessible papilla by duodenal obstruction, and patients with altered surgical anatomy13,14,15.
EUS-HGS involves transmural drainage of the left intrahepatic duct into the stomach. The main advantage is that it provides internal drainage, which is more physiological and, most of all, offers better patients&#39; comfort compared to PTBD12,16. This method is feasible for both hilar and distal malignant biliary obstruction. Here, we describe the technique of EUS-HGS as one of the methods of EUS-BD in a case of unresectable malignant hilar tumor.
A 71-year-old female was presented with painless jaundice and had a weight loss of 4 kg in 2 weeks duration. On examination, she was found to have scleral jaundice. Abdominal examination was unremarkable. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor involving the bifurcation of the right hepatic duct, the confluence of hepatic ducts and extrahepatic ducts, causing marked intrahepatic duct dilatation with lymphadenopathy and liver metastasis (Figure 1A). EUS fine needle biopsy (FNB) of the lesion was performed and it showed adenocarcinoma with positive CK7 and CA19-9 which was consistent with the diagnosis of hilar cholangiocarcinoma (Figure 1B). Her bilirubin levels were 212 &#181;mol/L (&#60;15) at presentation and CA19-9 levels were 305 U/mL. EUS-HGS was performed to provide relief in the biliary obstruction.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>10mm in size, 10cm in length Partially Covered Metallic Stent</td>
			<td>M.I Tech</td>
			<td>BPD10100-E180</td>
			<td></td>
		</tr>
		<tr>
			<td>Curved Linear Echoendoscopy</td>
			<td>Fujifilm</td>
			<td>EG-580UT</td>
			<td></td>
		</tr>
		<tr>
			<td>Electrocautary Dilator, 6Fr</td>
			<td>G-Flex</td>
			<td>CYSTO06U</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscopic Ultrasound System Processor</td>
			<td>Fujifilm</td>
			<td>SU-1</td>
			<td></td>
		</tr>
		<tr>
			<td>Expect 19-guage FNA Needle</td>
			<td>Boston Scientific</td>
			<td>M00555500</td>
			<td></td>
		</tr>
		<tr>
			<td>Hurricane Biliary Balloon Dilator, 4mm</td>
			<td>Boston Scientific</td>
			<td>M00545900</td>
			<td></td>
		</tr>
		<tr>
			<td>Visiglide 0.025-inch Guidewire, 4500mm in length</td>
			<td>Olympus</td>
			<td>G-240-2545S</td>
			<td></td>
		</tr>
	</tbody>
</table>

endoscopic ultrasound-guided biliary drainage: endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.
Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 &#181;mol/L (&lt;15) during presentation.
A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 &#181;mol/L and 14 &#181;mol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

The procedure was completed in approximately 30 min. There were no complications after the procedure and the patient was able to resume oral intake the next day. The bilirubin levels fell to 92 &#181;mol/L and she was discharged three days after the procedure. A repeated CT imaging was done which showed the stent in position with a resolution of biliary obstruction. The bilirubin level on the follow-up was 30 &#181;mol/L after 2 weeks post procedure and 14 &#181;mol/L at 4 weeks post procedure (Table 1)....

Watch this Scientific Journal Video about Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction at JoVE.com

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde ...

Research

JoVE Journal

Medicine

Surgical Procedures for a Rat Model of Partial Orthotopic Liver Transplantation with Hepatic Arterial Reconstruction

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as ...

Ultrasound-guided Transthoracic Intramyocardial Injection in Mice

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. ...

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an ...

Ultrasound-guided Intracardiac Injection of Human Mesenchymal Stem Cells to Increase Homing to the Intestine for Use in Murine Models of Experimental Inflammatory Bowel Diseases

Crohn&#39;s disease (CD) is a common chronic inflammatory disease of the small and large intestines. Murine and human mesenchymal stem cells (MSCs) have ...

International Expert Consensus and Recommendations for Neonatal Pneumothorax Ultrasound Diagnosis and Ultrasound-guided Thoracentesis Procedure

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic ...

Endaural Endoscopic Atticoantrotomy (Retrograde Mastoidectomy) using a Constant Suction Bone-drilling Technique

Endaural Endoscopic Atticoantrotomy Retrograde Mastoidectomy using a Constant Suction Bone-drilling Technique

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Ultrasound-Guided Induced Pluripotent Stem Cell-Derived Cardiomyocyte Implantation in Myocardial Infarcted Mice

The key objective of cell therapy after myocardial infarction (MI) is to effectively enhance the cell grafted rate, and human induced pluripotent stem ...