Endoscopic Ultrasound-Guided Hepaticogastrostomy via a Retrosternal Gastric Tube Conduit for Obstructive Cholangitis Caused by Ampullary Carcinoma: A Case Report

Subtotal esophagectomy with retrosternal gastric tube reconstruction alters upper gastrointestinal anatomy and can create two obstacles to endoscopic retrograde cholangiopancreatography (ERCP): displacement and rotation of the pylorus and proximal duodenum, which impede side-viewing duodenoscopy, and ampullary carcinoma, which may obscure the bile duct orifice and prevent selective cannulation. When endoscopic drainage fails, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) offers an alternative route for internal biliary decompression. Reports of EUS-HGS performed from within a retrosternal gastric tube conduit are limited. A 79-year-old woman with prior subtotal esophagectomy and retrosternal gastric tube reconstruction presented with acute cholangitis and obstructive jaundice caused by ampullary adenocarcinoma. ERCP was abandoned because tumor infiltration obscured the bile duct orifice. EUS-HGS was performed on the same day through the gastric conduit. A 19-gauge puncture and a double-guidewire technique enabled placement of a 7-Fr, 14-cm plastic stent without adverse events. Cholangitis resolved, diet was resumed four days later, and the stent remained patent at 57 days. Histology confirmed adenocarcinoma. EUS-HGS via a retrosternal gastric tube conduit was feasible and achieved internal biliary drainage in a patient with complex post-esophagectomy anatomy and failed ERCP.