Technique tips for fitting alignment of puncture route during EUS-guided hepaticogastrostomy (with video)

Technical tips for EUS-guided hepaticogastrostomy (EUS-HGS) can be divided into 4 steps: intrahepatic bile duct (IHBD) puncture, guidewire insertion, tract dilation, and stent deployment.[1] Various devices and tips for guidewire insertion, dilation devices, or dedicated stents have been reported.[2–5] Although IHBD puncture is the first step of EUS-HGS, the technical details have not been reported. During IHBD puncture, misalignment between the needle and the IHBD may be one reason for failed IHBD puncture. The technique to align the axis of the needle with that of the IHBD is described in this case report. A 46-year-old man was admitted to our hospital due to obstructive jaundice. Computed tomography showed a pancreatic tumor with IHBD dilatation. EUS-FNA was performed, and adenocarcinoma was diagnosed. Biliary drainage under endoscopic retrograde cholangiopancreatography guidance was attempted, but duodenoscope insertion failed due to duodenal obstruction. Therefore, EUS-guided antegrade stenting combined with HGS was attempted. First, IHBD puncture was performed using a 19-gauge needle [Figure 1A]. However, bile juice could not be aspirated because the axes of the needle and the IHBD were misaligned. To align the axes, the needle was pulled back within hepatic parenchyma [Figure 1B], and then the echoendoscope was gently pulled back [Figure 2A]. By doing so, the needle's axis could be adjusted, and then IHBD puncture was successfully performed [Figure 2B]. Bile juice aspiration was also successfully performed. A 0.025-inch guidewire was then inserted. After the endoscopic retrograde cholangiopancreatography catheter was inserted, lower common bile duct obstruction was observed. An uncovered self-expandable metal stent was then placed for antegrade stenting. Finally, EUS-HGS using partially covered self-expandable metal stent deployment was performed without any adverse events [Video 1].Figure 1: A, Intrahepatic bile duct puncture is performed, but bile juice cannot be aspirated. B, To adjust the axes of the needle and the intrahepatic bile duct, the needle is pulled back within the hepatic parenchyma.Figure 2: A, The echoendoscope is pulled back. B, Intrahepatic bile duct puncture is successful. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"The intrahepatic bile duct puncture is performed using a 19-gauge needle. However, bile juice cannot be aspirated. Because this failure occurs due to misalignment between the intrahepatic bile duct and the needle, the needle is pulled back within the hepatic parenchyma to align their axes. Then, the echoendoscope is pulled back. By doing so, we can successfully puncture the intrahepatic bile duct. After obtaining a cholangiogram with contrast medium injection, a 0.025-inch guidewire is deployed. After guidewire advancement into the intestine across the stricture site, antegrade stenting is performed. Finally, EUS-guided hepaticogastrostomy is performed.Videos are only available at the official website of the journal (http://www.eusjournal.com).","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_cwa2chap"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} In conclusion, the present technique may be helpful for failed IHBD puncture, although further evaluation is needed.