Practical Tips for Safe and Successful Endoscopic Ultrasound-Guided Hepaticogastrostomy: A State-of-the-Art Technical Review

Abstract

Currently, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is widely performed worldwide for various benign and malignant biliary diseases in cases of difficult or unsuccessful endoscopic transpapillary cholangiopancreatography (ERCP). Furthermore, its applicability as primary drainage has also been reported. Although recent advances in EUS systems and equipment have made EUS-HGS easier and safer, the risk of serious adverse events such as bile leak and stent migration still exists. Physicians and assistants need not only sufficient skills and experience in ERCP-related procedures and basic EUS-related procedures such as fine needle aspiration and pancreatic fluid collection drainage, but also knowledge and techniques specific to EUS-HGS. This technical review mainly focuses on EUS-HGS with self-expandable metal stents for unresectable malignant biliary obstruction and presents the latest and detailed tips for safe and successful performance of the technique.

Keywords: endoscopic ultrasound; endoscopic ultrasound-guided biliary drainage (EUS-BD); endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS); hepaticogastrostomy.

Figure 1

A flow diagram of step-by-step procedures in EUS-HGS.

Figure 2

Too shallow echoendoscope position in B3 puncture. In a shallow scope position, the angle formed by a needle and the bile duct on the hilar side is often acute, and a guidewire can easily go to the peripheral side ((A); ultrasound image, (B); fluoroscopic image).

Figure 3

Optimal echoendoscope position in B3 puncture. Pushing a scope while turning the large wheel upward rotates the EUS image clockwise and makes the angle between a needle and the bile duct on the hilar side obtuse, making a guidewire manipulation toward the hilar region easy (A). Fluoroscopic image (B).

Figure 4

Uneven Double Lumen Cannula (Piolax Medical Device). The double lumen catheter allows a second 0.035 inch guidewire to be inserted adjacent to the first 0.025 inch guidewire. (Courtesy of Piolax Medical Device).

Figure 5

Too shallow echoendoscope position in B2 puncture. In a shallow scope position, a needle and B2 are parallel to each other, making puncture difficult and increasing the risk of transesophageal puncture ((A); ultrasound image, (B); fluoroscopic image).

Figure 6

Optimal echoendoscope position in B2 puncture. Pushing a scope while turning the large wheel upward facilitates transgastric and reliable bile duct puncture ((A); ultrasound image, (B); fluoroscopic image).

Figure 7

Needles suitable for EUS-HGS. EZ shot 3 plus (Olympus Medical Systems) has a nitinol needle with a coil sheath (Courtesy of Olympus Medical Systems) (A). EchoTip Access Needle (Cook Medical) has a sharp stylet and blunt-tipped needle (Courtesy of Cook Medical) (B).

Figure 8

Preparation for puncture. The biopsy valve is attached to a dilation device (A). The needle stylet is removed, and a syringe filled with contrast medium is attached to the needle to pre-fill the lumen with contrast medium (B).

Figure 9

Changing a needle trajectory during biliary puncture. If a favorable biliary puncture line cannot be obtained due to the intervening vessels (A), pushing a scope after advancing a needle into the liver parenchyma to change the needle direction using the liver access point as a fulcrum (B).

Figure 10

Loop technique for redirection of a guidewire. If a guidewire is unintentionally advanced to the peripheral side, push the guidewire with rotation. When the tip of the guidewire is caught on a lateral branch (A), the guidewire will bend and form a loop by pushing force (B). If the loop is facing the hilar region, the guidewire can be advanced to the hilum by pushing further (C,D).

Figure 11

Moving scope technique for redirection of a guidewire. If a guidewire is unintentionally advanced to the peripheral side (A,B), push the scope while turning the large wheel upward to change the needle direction to the cranial side, allowing the guidewire to proceed toward the hilum (C).

Figure 12

Liver impaction technique for redirection of a guidewire. If a guidewire is unintentionally advanced to the peripheral side (A), pull the needle tip slightly into the hepatic parenchyma (B). The guidewire can be pulled without shearing because the tip of the needle is covered by the hepatic parenchyma (C). The guidewire is successfully manipulated toward hilum (D). Arrows indicate the tip of the needle.

Figure 13

Redirection of a guidewire using a rotatable sphincterotome. In cases where the guidewire cannot be advanced toward hilum even using double guidewire technique (A), the guidewire is manipulated with a rotatable sphincterotome by rotating and bending the tip of the catheter while securing the bile duct with another guidewire (B). The catheter is successfully advanced toward the hilar region (C).

Figure 14

One-step mechanical dilation devices. Hurricane (Boston Scientific) is a balloon dilator with a rigid shaft and stylet (Courtesy of Boston Scientific) (A). REN (Kaneka Medics) is a balloon dilator with an ultra-tapered tip adapted to a 0.025 inch guidewire (Courtesy of Kaneka Medics) (B). ES dilator (Zeon Medical) is a bougie dilator with an ultra-tapered tip adapted to a 0.025 inch guidewire. (Courtesy of Zeon Medical) (C).

Figure 15

Segmental dilation method for prevention of bile leak during balloon dilation. A balloon catheter is pushed into the bile duct as deeply as possible when dilating the bile duct wall (A) and pulled into the scope channel as long as possible when dilating the gastric wall to prevent overlap of the two dilated areas (B). The hepatic parenchyma left un-dilated is thought to prevent bile leakage due to the tamponade effect.

Figure 16

Partially covered SEMSs with anti-migration properties dedicated for EUS-HGS developed by Korean companies. GIOBOR stent (Taewoong medical) (A). HANARO stent BPD (M.I.Tech, Seoul, Korea) (B). Hybrid BONA stent (Standard Sci. Tech, Seoul, Korea) (C). DEUS (Standard Sci. Tech) (D). Courtesy of each company.

Figure 17

Impending delayed migration in Niti-S S-type stent (Taewoong Medical). A sufficient length of the gastric end of the stent is seen after the procedure (A). The next day’s CT shows that the intragastric stent length has shortened (B). Urgent endoscopy reveals impending migration of the gastric end of the stent (C).

Figure 18

Spring Stopper Stent (Taewoong Medical), which has a spring-type stopper as an anti-migration system at the gastric end. (Courtesy of Taewoong Medical).

Figure 19

Covered BileRush Advance (Piolax Medical Device). The partially covered laser-cut stent of 8 × 120 mm in size with a 2 cm uncovered portion on the hepatic end (A). The slim introducer with a 7 Fr shaft and 2.4 Fr tip (B). (Courtesy of Piolax Medical Device).

Figure 20

Endoscopic ultrasound-guided hepaticogastrostomy with a Covered BileRush Advance. Pre-procedure contrast-enhanced CT showed a long distance between the gastric body and left hepatic lobe (double arrow) (A). Post-procedure CT showed the Covered BileRush Advance fixed the gastric body near the left hepatic lobe by its jagged surface (arrow) (B).

Figure 21

Intra-channel (conduit) release method. After pulling the introducer until 1 to 2 cm release inside the channel, push the expanded part of the stent (arrow) to strongly press the gastric wall for keeping the stomach and liver close together (A). Stent deployment across the gastric wall can be directly confirmed by endoscopic view (B).