Endoscopic Ultrasound-Guided Biliary Drainage:Endoscopic Ultrasound Guided Hepaticogastrostomy in Malignant Biliary Obstruction. Patients with malignant biliary obstruction are often are unresectable and advanced at presentation. Palliative endoscopic biliary decompression is often needed in managing these cases.
ERCP is the primary method of biliary drainage whenever possible and if this fails or is contraindicated, PTBD is used as a salvage method. However, complications associated with PTBD are high, these include septicemia, cholangitis, bleeding, electrolyte loss, leakage, wound infection, and local discomfort. Endoscopic ultrasound-guided biliary drainage provides a physical alternative biliary drainage method.
Methods of EUS-BD commonly are EUS-guided choledochoduodenstomy, EUS-guided hepaticogastrostomy, EUS-guided anterograde stenting, and EUS-guided rendezvous procedure. In this case, we demonstrate the techniques of EUS-guided hepaticogastrostomy. The protocol is in accordance with the ethical guidelines of University of Malaya Medical Center.
Written consent and a detailed explanation of the procedure was obtained from the patient. Permission was also granted to produce the video of the procedure for educational purposes. This is a 71 year old lady with underlying hypertension and dyslipidemia.
She presented with painless jaundice and a weight loss of four kilograms for two weeks. Liver function tests shows that the bilirubin levels with 212 micromoles per liter. The CT scan revealed a hilar tumor causing marked intrahepatic duct dilatation with matted lymphadenopathies and liver metastasis.
On EUS, there's a four by five centimeter hilar mass with dilated intrahepatic ducts. A fine needle biopsy was done. Histology revealed that adenocarcinoma with positive CK7 and CA19-9, which is consistent with cholangiocarcinoma.
As you can see in the CT image, there is markedly dilated intrahepatic ducts showing that there is significant malignant biliary obstruction. And on EUS image, you can see the hilar coagulation at the hilum of the liver to which EUS-FNB was done. We proceeded with EUS-guided hepatico-gastrostomy in this patient to relieve her biliary obstruction.
Here are the equipments and accessories required for this procedure to be done. Firstly, the patient was placed in the prone position. Moderate sedation using intravenous infusion of propofol was given and titrated by the anesthetist.
This was followed by identifying the dilated left intrahepatic duct and needle access into the targeted intrahepatic duct. The linear echoendoscope was advanced making sure it passes the gastro-esophageal junction. The dilated segment 3 intrahepatic ducts was identified as seen in this image.
The angle of the tip of the echoendoscope was slightly tilted upwards to facilitate the next step in needle puncture. Doppler ultrasound was first used to ensure that there were no intervening blood vessels around the targeted intrahepatic duct. Using a 19 gauge needle, the segment 3 intrahepatic duct was puncture.
Using a 10 mil syringe preloaded with seven mils of contrast solution, gentle expiration was done to ensure that bowel was aspirated. This was to confirm the success of biliary access. Following that contrast injection and fills to opacify the left intrahepatic duct and the rest of the biliary system.
Guidewire manipulation. A 0.025 inch guidewire was used to navigate into the left intrahepatic duct under fluoroscopic guidance. The guidewire was successfully cannulated across into the right intrahepatic duct.
Fistula tract dilation. The fistula tract is dilated using a 6 Fr electrocautery dilator in addition to using a four millimeter billary balloon dilator. The balloon inflation time was approximately five seconds.
While doing this, the position of the accessories was constantly monitored using both the sonographic and fluoroscopic image, ensuring that the wire was visible and the echoendoscope position was maintained. This was to ensure a smooth transition in the exchange of accessories, which is very important. Stent deployment.
A 10 millimeter size partially covered biliary stent with the length of 10 centimeter was deployed under fluoroscopic guidance. The stent has a three centimeter uncovered distal portion and the seven centimeter covered proximal portion. The uncovered portion must be ensured to be within the intrahepatic duct as the markers shown in this image.
The distal end of the stent opens in the intrahepatic duct and the proximal end within the working channel of the echoendoscope subsequently releasing it into the stomach with bile seen flowing within the stent. The procedure took approximately 30 minutes. The patient was well after the procedure without any complications.
Bilirubin levels fell from 212 micromoles per liter to 92 micromoles per liter. She was discharged three days after the procedure and a repeat CT scan was done after two weeks of the procedure. Upon follow up, the bilirubin levels were at 30 micromoles per liter after two weeks and 14 micromoles per liter after four weeks.
This is the repeated CT scan at two weeks after the procedure. The stent can be seen in position with bilirubin within. A total of 15 patients underwent EUS-guided hepaticogastrostomy for unresectable malignant biliary obstruction in our institution and the results are shown in this table.
EUS-guided hepaticogastrostomy is a feasible and safe method of biliary drainage in unresectable malignant biliary obstruction. It can coexist with current biliary drainage methods, such as ERCP and PTBD. Indications are in patients who have failed ERCP, inaccessible papilla, those who have alter anatomy, and in some selected patients, a primary mode of biliary drainage.
This procedure, however, is contraindicated in patients who are unfit for endoscopy, those who have poor life expectancy, coagulopathy and present of ascites.
