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Balloon guidewire technique during EUS-guided hepaticogastrostomy
Akihisa Ohno1, Toyoma Kaku1, Nao Fujimori2
1 Department of Gastroenterology; Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
2 Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| Date of Submission | 02-Mar-2021 |
| Date of Acceptance | 12-Jul-2021 |
| Date of Web Publication | 08-Nov-2021 |
Correspondence Address:
Toyoma Kaku,
Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563
Japan
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/EUS-D-21-00067 PMID: 34755704
Recently, EUS-guided hepaticogastrostomy (EUS-HGS) has been widely performed as an alternative method of biliary drainage when ERCP fails.[1],[2] Guidewire (GW) manipulation is the most challenging step during the procedure. When inserting GW into the bile duct during EUS-HGS, in some cases, GW could only be advanced into the peripheral bile duct. There are only a few reports regarding the GW insertion technique,[3],[4] and no standard method has been established during EUS-HGS to properly advance the GW toward the hilar bile duct. Herein, we report a new GW technique using a balloon catheter. First, we advanced a GW deep into the peripheral bile duct. Second, a multi-lumen balloon catheter (Bouncer; Cook Medical, Tokyo, Japan) [Figure 1] was inserted, and the balloon was inflated in the bile duct. Third, we inserted an additional GW from the second lumen and advanced it toward the hilar bile duct. | Figure 1: The photograph image of the multiple lumen balloon catheter (Bouncer; COOK Medical Japan). An additional guidewire is inserted from the second lumen. It hits the inflated balloon and can be guided towards a different direction from the first guidewire (arrow)
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An 85-year-old man was admitted to our hospital with obstructive jaundice due to unresectable pancreatic malignant lymphoma. He had previously undergone the placement of a fully covered metallic stent for distal bile duct stricture 2 years back. Although we performed ERCP, internal drainage failed due to difficulty in inserting a GW into the intrahepatic bile duct. Therefore, we performed EUS-HGS as an alternative treatment. The left intrahepatic duct was punctured using a 19G needle, and a contrast medium was injected. A 0.025-inch GW only advanced into the peripheral bile duct [Figure 2]a. Two GWs were placed in the peripheral bile duct using an uneven double-lumen catheter (Piolax Medical Devices, Kanagawa, Japan). The novel Bouncer catheter was inserted, and the balloon was inflated in the bile duct. The third GW was inserted into the hilar bile duct from the second lumen [Figure 2]b. A plastic stent was successfully deployed without any complications [Figure 2]c. This technique may be useful for GW manipulation during EUS-HGS when a GW can only be advanced into the peripheral bile duct. | Figure 2: Fluoroscopic image findings: (a) the guidewire only advances into the peripheral bile duct; (b) guidewire bounces off the balloon and advances into the hilar bile duct; (c) a plastic stent is successfully placed
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Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Guo J, Giovannini M, Sahai AV, et al. A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction. Endosc Ultrasound 2018;7:356-65.  |
| 2. | Uemura RS, Khan MA, Otoch JP, et al. EUS-guided choledochoduodenostomy versus hepaticogastrostomy: A systematic review and meta-analysis. J Clin Gastroenterol 2018;52:123-30. |
| 3. | Ogura T, Masuda D, Takeuchi T, et al. Liver impaction technique to prevent shearing of the guidewire during endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2015;47:E583-4. |
| 4. | Ogura T, Yamada M, Yamada T, et al. Reverse knuckle guidewire insertion technique for endoscopic ultrasound-guided hepaticogastrostomy using a novel 0.025-inch guidewire. Endoscopy 2020;52:E418-9. |
[Figure 1], [Figure 2]
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