Stent release within scope channel technique to prevent stent migration during EUS-guided hepaticogastrostomy (with video).

Stent migration may be sometimes fatal for EUS-guided biliary drainage such as hepaticogastrostomy (HGS) because it is not adhesions between the biliary tract and the stomach.[12345] Stent migration can be occurred in two situations. First is early stent migration. In this situation, stent migration occurs due to stent deployment within abdominal cavity. Second is late stent migration due to stent shortening. If the distance between the hepatic parenchyma and the stomach wall is far, stent migration may occur due to stent shortening. In addition, in this situation, fistula may not be created. If fistula is not created, it may be led to several adverse events such as bile leak or difficult to perform reintervention through EUS-HGS stent. To prevent early and late stent migration or minimize, the stent length of abdominal cavity to create the fistula, we herein described technical tips of EUS-HGS using stent release within scope channel technique [Video 1].

The intrahepatic bile duct was punctured using a 19-gauge FNA needle. Then, the 0.025-inch guidewire (VisiGlide; Olympus Medical Systems, Tokyo, Japan) was inserted into the intrahepatic bile duct. Next, the bile duct and stomach wall were each dilated using 4 mm balloon catheter. Stent delivery system was inserted into the confluence of liver segment 2 and segment 3. Next, stent release is carefully performed from the intrahepatic bile duct to the hepatic parenchyma [Figure 1a]. After this procedure, to stabilize the EUS scope, until the stent was deployed up to 1 cm within the EUS scope [Figure 1b]. Then, EUS scope was pulled little bite after stent delivery system was pushed [Figure 1c]. Finally, stent release was performed under mainly endoscopic view guidance [Figure 1d]. In stent release within scope channel technique, stent deployment completely is performed compressing between liver parenchyma and the stomach wall. Therefore, candy sign may not be observed, and the distance between hepatic parenchyma and the stomach wall may be near [Figure 2a and b].

Figure 1

(a) Stent release is performed from the intrahepatic bile duct to hepatic parenchyma (arrow). (b) The EUS scope was stabilized until the stent is deployed up to 1 cm within the EUS scope (arrow). (c) The EUS scope is pulled little bite after stent delivery system is pushed on endoscopic view guidance. (d) Stent placement is completely performed

Figure 2

(a) The distance between hepatic parenchyma and stomach wall is 63.6 mm on computed tomography imaging before EUS hepaticogastrostomy. (b) The distance between hepatic parenchyma and stomach wall is 5.7 mm on computed tomography imaging the day after EUS hepaticogastrostomy

Our method has two important points. First, stent release performed within scope channel across the stomach wall; therefore, early stent migration can be prevented. Second, this technique may adhere the hepatic parenchyma and the stomach wall; therefore, late stent migration or several adverse events such as bile leakage can be prevented. The presented technique may have clinical impact during EUS-HGS.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.