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Ingrown and exteriorized hilar tumor through hepaticogastrostomy stent causing upper gastrointestinal bleeding (with video)


1 Department of Medicine, Division of Gastroenterology, Excellence Center for Gastrointestinal Endoscopy, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Department of Gastroenterology, Calmette Hospital, Phnom Penh, Cambodia
2 Department of Medicine, Division of Gastroenterology, Excellence Center for Gastrointestinal Endoscopy, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
3 Department of Medicine, Division of Gastroenterology, Excellence Center for Gastrointestinal Endoscopy, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society; Excellence Center for Gastrointestinal Endoscopy, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, and Pancreas Research Unit, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Date of Submission31-Oct-2021
Date of Acceptance15-Feb-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Pradermchai Kongkam,
1873, GI Endoscopy unit, 10th floor Bhumisirimunkalanusorn building, King Chulalongkorn Memorial Hospital, Rama IV road, Pathumwan, Bangkok 10330
Thailand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00231

PMID: 35899902



How to cite this URL:
Oung B, Luangsukrerk T, Plaidum S, Kongkam P. Ingrown and exteriorized hilar tumor through hepaticogastrostomy stent causing upper gastrointestinal bleeding (with video). Endosc Ultrasound [Epub ahead of print] [cited 2022 Aug 13]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=351308

Interventional EUS has evolved rapidly in recent years, with a variety of therapeutic procedures, including EUS-guided biliary drainage (EUS-BD). With the development of new tools and techniques, this procedure has become more effective, safer, and simpler, which is recommended in case of failure of conventional procedures such as ERCP.[1],[2]

A 69-year-old male diagnosed with unresectable malignant hilar biliary obstruction (MHBO) presented with recurrent biliary obstruction (RBO). Fourteen months ago, the patient had MHBO and was treated with bilateral self-expandable metal stents (SEMS) (side-by-side manner), and another 10 mm × 120 mm partially covered SEMS (GIOBOR; Taewoong-Medical Co, Seoul, South Korea) as a hepaticogastrostomy (HGS) stent drained from intrahepatic bile duct (IHD) segment 3. Subsequently, the patient had percutaneous biliary drainage drained from IHD segments 7 and 8 [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. In this visit, the patient presented with melena and obstructive jaundice suspected for RBO. An emergency gastroscopy revealed tumor ingrown through intact HGS stent and exteriorized into the gastric lumen with blood clot, responsible for bleeding [Figure 2] and [Video 1 [Additional file 1]].
Figure 1: Biliary drainage. (a) Cholangioscopy showed malignant hilar stricture; (b) Two uncovered self-expandable metal stents were placed side-by-side; (c) a 10 mm × 120 mm partially covered self-expandable metal stents (GIOBOR; Taewoong-Medical Co, Seoul, South Korea) as a hepaticogastrostomy stent drained from intrahepatic bile duct segment 2 and 3; (4) fluoroscopic view showed a combination of a self-expandable metal stent placed by EUS-hepaticogastrostomy procedure, two self-expandable metal stents placed by endoscopic retrograde cholangiopancreatography and a plastic tube placed by percutaneous biliary drainage procedure

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Figure 2: Tumor grown on hepaticogastrostomy stent in the gastric lumen

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EUS-HGS was known to have advantage over the ERCP drainage in terms of longer stent patency time by avoiding the risk of tumor ingrown with reported stent patency up to 402 days.[3] To our best knowledge, this is the first case report of tumor gown within an HGS stent and went into the intragastric part of the stent, causing upper gastrointestinal bleeding after a period of 425 days from the index EUS-HGS. Hence, MHBO which is sufficiently drained by a combination of endoscopic and radiological approach, provide long survival to the patient, allowing tumor to grow inward through HGS stents.

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 name 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

Pradermchai Kongkam is an Editorial Board Member of the journal. This article was subject to the journal's standard procedures, with peer review handled independently of this editor and her research group.



 
  References Top

1.
Khoo S, Do ND, Kongkam P. Efficacy and safety of EUS biliary drainage in malignant distal and Hilar biliary obstruction: A comprehensive review of literature and algorithm. Endosc Ultrasound 2020;9:369-79.  Back to cited text no. 1
    
2.
Giovannini M. EUS-guided hepaticogastrostomy. Endosc Ultrasound 2019;8:S35-9.  Back to cited text no. 2
    
3.
Paik WH, Park DH. Outcomes and limitations: EUS-guided hepaticogastrostomy. Endosc Ultrasound 2019;8:S44-9.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

 
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