Guidewire technique and nasobiliary duct–assisted secondary EUS-guided biliary drainage

A 75-year-old woman was hospitalized for jaundice and high fever. She had undergone Roux-en-Y hepaticojejunostomy because of hilar cholangiocarcinoma 1 year before. Endoscopic retrograde cholangiopancreatography was performed, but the guidewire failed to pass the stenosis at the origin of the left hepatic duct [Figure 1]. Due to the increasing jaundice, we opted for EUS-guided biliary drainage (EUS-BD), instead of percutaneous transhepatic cholangiography drainage, to relieve biliary obstruction. Segment 2 (B2) was punctured, but the guidewire could not pass through the narrow bilioenteric anastomosis. Gastrointestinography showed the anastomosis was linearly narrow and angulated [Figure 2]. The fistula was dilated with a 6F coaxial electric cautery (Cysto-gastro-set; ENDO-FLEX, Voerde, Germany) and then with a 7F biliary dilation catheter (Soehendra biliary dilation catheter; Cook Medical, Bloomington, IN) that penetrated into the abdominal cavity; localized contrast medium was observed on plain x-ray. A single-pigtail nasobiliary drainage tube was inserted to relieve biliary leakage [Figure 3]. The abdominal perforation resolved 5 days later. The guidewire was inserted through the nasobiliary duct, passed through the bilioenteric anastomosis, and coiled in the intestinal cavity [Figure 4]. Rendezvous procedure was performed successfully. The nasobiliary tube was cut using scissor forceps, and the distal part was placed into the gastric cavity, as a modified plastic stent [Figure 5]. Bilirubin decreased fast, and the patient was discharged a week later without adverse events.Figure 1: The guidewire failed to pass the stenosis at the origin of the left hepatic duct during endoscopic retrograde cholangiopancreatography procedure.Figure 2: EUS-BD was performed; the anastomosis was linearly narrow and angulated.Figure 3: Localized contrast medium was observed on plain x-ray; a single-pigtail nasobiliary drainage tube was inserted.Figure 4: The guidewire was inserted through the nasobiliary duct, passed through the bilioenteric anastomosis, and coiled in the intestinal cavity.Figure 5: The nasobiliary tube was cut using scissor forceps, and the distal part was placed into the gastric cavity, as a modified plastic stent.This is the first reported case of guidewire technique and nasobiliary duct–assisted secondary EUS-BD. The patient experienced complications in EUS-BD for the first time. After the symptoms improved, we followed the nasobiliary duct to adjust the guidewire. The second EUS-BD EUS-Rendezvous (EUS-RV) was successfully completed. The nasobiliary duct was used as a modified plastic stent for EUS-Hepaticogastrostomy (EUS-HGS). It is to be hoped our case can help you get inspiration.