Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Summary

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Abstract

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.

Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 µmol/L (<15) during presentation.

A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 µmol/L and 14 µmol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

Introduction

Patients with malignant biliary obstruction are often unresectable and advanced at presentation^1,2. As a result, palliative endoscopic biliary decompression is often needed in managing these cases^3,4,5. According to current recommendations, Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary method of biliary drainage, whenever possible, and if this fails or is contraindicated, Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method^6,7,8. However, there are certain complications associated with PTBD, which include septicemia, cholangitis, bleeding, electrolyte lost, leakage, wound infection, local discomfort; these complications are reported to be as high as 53.2%⁹. The emergence of Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method to address this gap. The principal technique of EUS-BD involves the use of endosonographic imaging to guide access to the biliary system via the gastrointestinal tract to provide therapeutic decompression of an obstructed biliary system.

EUS-BD was first performed in 2001, and since then, this method of biliary drainage has evolved over the years¹⁰. Methods of EUS-BD commonly are EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided Anterograde stenting (EUS-AS), and EUS-guided Rendezvous (EUS-RV)^11,12. To date, the indications for EUS-BD include patients who have failed ERCP, patients having an inaccessible papilla by duodenal obstruction, and patients with altered surgical anatomy^13,14,15.

EUS-HGS involves transmural drainage of the left intrahepatic duct into the stomach. The main advantage is that it provides internal drainage, which is more physiological and, most of all, offers better patients' comfort compared to PTBD^12,16. This method is feasible for both hilar and distal malignant biliary obstruction. Here, we describe the technique of EUS-HGS as one of the methods of EUS-BD in a case of unresectable malignant hilar tumor.

A 71-year-old female was presented with painless jaundice and had a weight loss of 4 kg in 2 weeks duration. On examination, she was found to have scleral jaundice. Abdominal examination was unremarkable. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor involving the bifurcation of the right hepatic duct, the confluence of hepatic ducts and extrahepatic ducts, causing marked intrahepatic duct dilatation with lymphadenopathy and liver metastasis (Figure 1A). EUS fine needle biopsy (FNB) of the lesion was performed and it showed adenocarcinoma with positive CK7 and CA19-9 which was consistent with the diagnosis of hilar cholangiocarcinoma (Figure 1B). Her bilirubin levels were 212 µmol/L (<15) at presentation and CA19-9 levels were 305 U/mL. EUS-HGS was performed to provide relief in the biliary obstruction.

Protocol

The protocol was performed in accordance with the ethical guidelines of the University of Malaya Medical Center. Written consent was obtained, and a detailed explanation of the procedure was provided to the patient. Permission was also granted to produce the video of the procedure for educational purposes.

1. Positioning and sedation

1. Place the patient in a prone position. Provide moderate sedation using intravenous infusion of Propofol. Ensure the infusion is titrated by the anesthetist.

2. Identifying the suitable target dilated left intrahepatic ducts

1. Advance the linear echoendoscope making sure it passes the gastro-esophageal junction.
2. Place the tip of the echoendoscope at the lesser curvature of the gastric cavity and proceed to identify the dilated left intrahepatic duct (IHD).
3. Perform fluoroscopic imaging to ascertain the position of the echoendoscope. The tip of the echoendoscope must be placed at the lesser curvature of the gastric cavity, as stated previously. Always maintain the echoendoscope position and stabilize with periodic checks using fluoroscopic imaging throughout the procedure.
4. Identify the dilated segment 3 IHD. Slightly tilt the angle of the tip of the echoendoscope upward to facilitate the next step in needle puncture.
   ​NOTE: Subsequent steps of the procedure involve inserting and exchanging of accessories via the working channel of the echoendoscope throughout the procedure.

3. Needle access into the targeted dilated left intrahepatic duct

1. Perform Doppler ultrasound to ensure that there are no intervening blood vessels around the targeted IHD.
2. Using a 19 G needle, puncture the segment 3 IHD (Figure 2A). Using a 10 mL syringe preloaded with 7 mL of the contrast solution, gently aspirate the bile solution, this was to confirm the success of biliary access.
3. Following that, perform contrast injection to opacify the left IHD and the rest of the biliary system.

4. Guidewire manipulation

1. Use a 0.025-inch guidewire to navigate into the left IHD under the fluoroscopic guidance.
2. Cannulate the guidewire across into the right intrahepatic duct (Figure 2B).
   ​NOTE: Ideally, the guidewire should be manipulated deep into the common bile duct; however, it was not possible in this case due to the obstructing hilar tumor.

5. Fistula tract dilation

1. Dilate the fistula tract using a 6 Fr electrocautery dilator in addition to using a 4 mm biliary balloon dilator (Figure 2C).
   NOTE: Fistula tract dilation is required to facilitate insertion of the biliary stent later.
2. Perform balloon inflation for approximately 5 s.
   NOTE: While doing these, monitor the position of the accessories monitored using both the sonographic and fluoroscopic image, ensuring that the wire is visible and the echoendoscope position is maintained. This is done to ensure a smooth transition during the exchange of accessories which is very important.

6. Stent insertion and deployment

1. Deploy a 10 mm sized partially covered biliary stent (length of 10 cm) under fluoroscopic guidance (Figure 3A).
   NOTE: The stent has a 3 cm uncovered distal portion and a 7 cm covered proximal portion. The uncovered part must be within the intrahepatic duct (Figure 3C). Approximately 3 cm of the covered part of the stent is left in the gastric cavity to prevent inward migration of the stent (Figure 3B).
2. Ensure that the distal end of the stent opens in the IHD. Deploy the proximal end within the working channel of the echoendoscope and subsequently release into the stomach with bile seen flowing within the stent.

Results

The procedure was completed in approximately 30 min. There were no complications after the procedure and the patient was able to resume oral intake the next day. The bilirubin levels fell to 92 µmol/L and she was discharged three days after the procedure. A repeated CT imaging was done which showed the stent in position with a resolution of biliary obstruction. The bilirubin level on the follow-up was 30 µmol/L after 2 weeks post procedure and 14 µmol/L at 4 weeks post procedure (Table 1).

Discussion

The above case description illustrates the possibility of using EUS-HGS as an alternative biliary drainage method in the management of biliary tract malignancies compared to existing methods such as ERCP and PTBD. Among the steps described above, identifying, and accessing the correct intrahepatic duct, guidewire manipulation, and stent deployment are the three main crucial steps in ensuring that the procedure can be performed successfully and safely.

In choosing the ideal liver segment for bi...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
10mm in size, 10cm in length Partially Covered Metallic Stent	M.I Tech	BPD10100-E180
Curved Linear Echoendoscopy	Fujifilm	EG-580UT
Electrocautary Dilator, 6Fr	G-Flex	CYSTO06U
Endoscopic Ultrasound System Processor	Fujifilm	SU-1
Expect 19-guage FNA Needle	Boston Scientific	M00555500
Hurricane Biliary Balloon Dilator, 4mm	Boston Scientific	M00545900
Visiglide 0.025-inch Guidewire, 4500mm in length	Olympus	G-240-2545S