Single-session EUS-guided gastroenterostomy and hepaticogastrostomy using dedicated metal stents (with videos)
Andrea Anderloni1, Alessandro Fugazza2, Marco Spadaccini2, Matteo Colombo2, Roberto Gabbiadini2, Licia Vanessa Siracusano3, Tiziana Pressiani3, Alessandro Repici2 1 Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS,Rozzano, Italy 2 Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center–IRCCS, Rozzano; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy 3 Department of Medical Oncology and Hematology, Humanitas Clinical and Research Center–IRCCS, Rozzano, Italy
Date of Submission
06-Jul-2020
Date of Acceptance
19-Aug-2020
Date of Web Publication
12-Jan-2021
Correspondence Address: Andrea Anderloni, Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS,Rozzano Italy
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/eus.eus_60_20
PMID: 33463553
How to cite this URL: Anderloni A, Fugazza A, Spadaccini M, Colombo M, Gabbiadini R, Siracusano LV, Pressiani T, Repici A. Single-session EUS-guided gastroenterostomy and hepaticogastrostomy using dedicated metal stents (with videos). Endosc Ultrasound [Epub ahead of print] [cited 2021 Apr 21]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=306746
A 46-years-old female with unresectable pancreatic adenocarcinoma previously palliated by a transpapillary biliary plastic stent placement, was referred to our unit because of the onset of gastric outlet obstruction (GOO) symptoms, along with jaundice relapse. Endoscopic assessment confirmed a neoplastic stricture of the duodenal bulb with an inaccessible major papilla. Single-session EUS-guided gastroenterostomy (GE) and biliary drainage (BD) was therefore planned.
A 7.5 Fr nasobiliary tube was introduced into the proximal jejunum, and a blue-tinged, contrasted solution was instilled to distend the jejunal lumen. After EUS confirmation of the target loop by aspirating the blue-tinged solution with a 19-gauge needle, EUS-GE was performed by a 15 mm × 10 mm cautery-assisted lumen apposing metal stent (EC-LAMS, Hot-Axios, Boston Scientific Corporation Inc., Marlborough, MA, USA) placement (Video 1).
Since the duodenal infiltration, with distance between the duodenal wall and the common bile duct up to 12 mm [Figure 1], did not allow a stable position, BD was obtained by performing an EUS-guided hepaticogastrostomy (EUS-HGS). A specifically dedicated 10 mm × 80 mm partially-covered stent (Hanarostent Biliary stent, M. I. Tech, Seoul, Rep. South Korea) was placed under endoscopic and fluoroscopic guidance. This stent was conceived as asymmetrically covered and shaped, in order to have its uncovered-tubular end into the intrahepatic ducts, and the covered-flanged end into the gastric cavity, to reduce the risk of migration (Video 2).
Figure 1: Dedicated stents for EUS-GE and -HGS: final fluoroscopic view.
No procedure-related adverse events were reported.
Successful single session management of concomitant biliary and duodenal obstruction has been described, by EUS-choledochoduodenostomy and subsequent duodenal stent placement[1].
In this case, we preferred to perform an EUS-GE followed by EUS-HGS as they have emerged as a feasible and effective novel alternative approach for palliation of concomitant biliary and GOO.[2],[3],[4]
Keeping the distance from the neoplastic epicenter both the approaches could offer long-lasting stents patency. As a matter of fact since specifically dedicated devices (i.e., LAMS) have been developed, we are witnessing the escalation of EUS-guided therapeutic procedures.[5] The development of dedicated stents for different indications (such as EUS-HGS) could further increase the procedural feasibility offering customized approaches to our patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Anderloni A, Buda A, Carrara S, et al. Single-session double-stent placement in concomitant malignant biliary and duodenal obstruction with a cautery-tipped lumen apposing metal stent. Endoscopy 2016;48:E321-2.
Ogura T, Chiba Y, Masuda D, et al. Comparison of the clinical impact of endoscopic ultrasound-guided choledochoduodenostomy and hepaticogastrostomy for bile duct obstruction with duodenal obstruction. Endoscopy 2016;48:156-63.
Anderloni A, Leo MD, Carrara S, et al. Endoscopic ultrasound-guided transmural drainage by cautery-tipped lumen-apposing metal stent: Exploring the possible indications. Ann Gastroenterol 2018;31:735-41.
