What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment modality for bile duct obstruction. When ERCP is unsuccessful, percutaneous transhepatic biliary drainage can be an alternative method. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a treatment option for biliary obstruction, especially after ERCP failure. EUS-BD offers transluminal intrahepatic and extrahepatic drainage through a transgastric and transduodenal approach. EUS-guided hepaticogastrostomy (EUS-HGS) is an excellent choice for patients with hilar strictures or those with a surgically altered anatomy. The optimal steps in EUS-HGS are case selection, bile duct visualization, puncture-site selection, wire insertion and manipulation, tract dilation, and stent placement. Caution should be taken at each step to prevent complications. Dedicated devices for EUS-HGS have been developed to improve the technical success rate and reduce complications. This technical review focuses on the essential practical points at each step of EUS-HGS.

Keywords: Bile duct obstruction; Biliary fistula; Drainage; Endoscopic ultrasonography.

Fig. 1.

Illustration of the liver anatomy, biliary tree, and vascular structures.

Fig. 2.

(A) EUS image of segment 2 (B2) and segment 3 (B3) of the intrahepatic bile duct. (B) Schematic of the echoendoscope position. EUS, endoscopic ultrasound.

Fig. 3.

(A) The needle direction aims toward the hepatic hilum allowing successful wire passage. (B) The needle direction is perpendicular to the target bile duct making wire manipulation toward the hilum difficult. (C) Unstable scope position causing looping and displacement of the equipment.

Fig. 4.

Insufficient stent traction during deployment results in trapping of the stent between the liver and stomach.

Fig. 5.

EUS-HGS-guided treatment of a hepaticojejunostomy anastomotic stricture. (A) EUS-HGS-guided placement of a fully covered metallic stent. (B) Antegrade balloon dilation through the hepaticogastrostomy tract 1 month later. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy.