Biliary Stone Extraction via Hepaticoenterostomy in Patients with Surgically Altered Anatomy or Inaccessible Papilla: A Multicenter Retrospective Study

Background and aims: EUS-guided biliary drainage (EUS-BD), which is recommended as an alternative to ERCP for treating malignant bile duct obstruction, is increasingly applied for benign biliary diseases. This study evaluated the success and complication rates associated with stone extraction via EUS-hepaticoenterostomy (hepaticogastrostomy (HGS) or hepaticojejunostomy (HJS)). Methods: This retrospective multicenter study included patients with surgically altered anatomy (SAA) or benign duodenal stenosis who underwent EUS-guided hepaticoenterostomy for stone extraction. The primary endpoint was successful bile duct clearance. The secondary endpoints included the technical success and morbidity rates (adverse event rates within 30 days after each endoscopic procedure) of EUS-hepaticoenterostomy, and the recurrence rate of biliary stones. Results: Thirty-four patients (25 men, 9 women; median age: 72 years; IQR, 66-80), were included between 2015 and 2024. Thirty-two patients had SAA and two had benign duodenal stenosis. The technical success rate of EUS-hepaticoenterostomy was 88% (30/34) with bile duct clearance achieved in all successful cases.. Among the 16 patients in whom cholangioscopy-assisted intraductal electrohydraulic lithotripsy (EHL) was attempted, technical success was achieved in 93% (15/16), while successful stone removal was achieved in 88% (14/16). EUS-HES related adverse events occurred in 38% (13/34) of patients, including grade III–IV adverse events in 21% (7/34). Cholangitis was the most frequent complication (15%). No mortality was reported. Conclusions: EUS-hepaticoenterostomy is an effective option for treating bile duct stones in patients with altered anatomy. This approach also enables cholangioscopy-assisted intraductal lithotripsy for large stones, thereby expanding the therapeutic options for managing complex bile duct stones.