EUS-guided hepaticojejunostomy for biliary obstruction in near-total gastrectomy with Roux-en-Y: Trials and tribulations (with videos)

EUS-guided hepaticogastrostomy is utilized for biliary drainage in complex cases. EUS-guided hepaticojejunostomy (EUS-HJ) can be considered in cases of near-total gastrectomy. Technical considerations include jejunal diameter, fibrotic tissue, and angulated access points to the intrahepatic ducts. 1, 2 We present a challenging case of EUS-HJ to treat malignant biliary obstruction in a patient with gastric cancer and near-total gastrectomy with Roux-en-Y reconstruction. Endoscopy revealed a healthy esophagus, minimal gastric pouch, and jejunal reservoir Figure 1. EUS noted dilation of intrahepatic ducts. Left intrahepatic ducts (LIHDs) were accessed with a 19-gauge needle. Contrast cholangiogram confirmed a dilated biliary tree Figure 2. Despite HJ tract dilation with a 4-mm balloon, attempts to transverse the tract with a fully covered self-expanding metal stent (FCSEMS) with flexible tapered tip were unsuccessful Video 1. Then, unexpectedly, the fluoroscopy monitor blacked out. Despite the efforts of endoscopy staff to fix the monitors as quickly as possible, 20 minutes elapsed before monitoring resumed. Upon resumption, scope and EUS position were altered. The delay may have led to unnecessary bile leakage as the HJ tract had just been dilated. The scope and EUS were promptly readjusted. A stiff catheter tip, 10 mm × 8 cm, FCSEMS successfully traversed the HJ tract, with the distal end in the LIHD and proximal end in the jejunum, and an anchoring 7F × 15-cm double pigtail stent was placed within the FCSEMS Video 2. Figure 1: A healthy esophagus with minimal 1-cm gastric pouch (A) and jejunal reservoir (B) were noted on endoscopy. Figure 2: Contrast cholangiogram confirmed a dilated biliary tree after the left intrahepatic ducts were accessed with a 19-gauge needle. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1", "caption": "Attempt to traverse the hepaticojejunal tract. 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": "1ₑsju059y", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 2", "caption": "Successful placement of self-expanding metal stent into the hepaticojejunal tract. 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": "1ₑbz82y65", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} The FCSEMS was readjusted by using rat-tooth forceps to pull it more luminally Video 3. A second 10 mm × 8-cm FCSEMS was placed within the original FCSEMS to prevent overcorrection Video 4. The distal end of the second FCSEMS was noted securely in LIHDs and the proximal end within the original FCSEMS Figures 3, 4. There were no complications. Bilirubin normalized postprocedure. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 3", "caption": "Adjustment of stentwith rat-tooth forceps. 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": "1₀ftqypvt", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 4", "caption": "lnsertion of second self-expanding metal stent into the hepaticojejunal tract. 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": "1blhnavl2", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} Figure 3: The distal end of the second bridging fully covered self-expanding metal stent was noted securely in the left intrahepatic ducts and the proximal end within the original fully covered self-expanding metal stent. Figure 4: Fluoroscopy confirming proper stent position. This case demonstrates that EUS-HJ is a safe, feasible technique for biliary decompression even in the setting of uniquely complex, surgically altered anatomy with considerable fibrosis. The case also highlights unique pitfalls of EUS-guided biliary drainage when certain endoscopic unit equipment/medical devices fail. It is important to anticipate and troubleshoot these issues when unforeseen circumstances inevitably occur. Source of Funding None.