EUS guided hepatico-gastrostomy in a pregnant patient with Roux-en-Y hepatico-jejunostomy anatomy. These are our disclosures. A 22-year-old woman presented 17 weeks pregnant with worsening nausea, vomiting, and inability to tolerate oral intake. She previously had incurred a bile duct transsection during cholecystectomy, requiring a Roux-en-Y hepatico-jejunostomy reconstruction. This was complicated by a bile leak, which required balloon-assisted enteroscopy ERCP, and placement of a fully covered, self-expandable metal stent, leading to resolution of the bile leak. Subsequently, the biliary stent was removed. Present labs were notable for leukocytosis, elevated alkaline phosphatase, and an elevated total bilirubin. MRCP revealed mildly dilated intra-hepatic bile ducts up to 5 mm extending to the level of the hepatico-jejunostomy, suggestive of an anastomotic stricture. Endoscopic methods. EUS-guided biliary access with 19-gauge needle. Hepatico-gastrostomy creation with balloon dilation of the hepatico-gastrostomy tract. Placement of two overlapping, fully covered, self-expandable metal stents across hepatico-gastrostomy. Dilation of hepatico-jejunostomy stricture. Placement of double pigtail plastic stents to treat hepatico-jejunostomy stricture. Clinical implications. Pregnant patients with surgically altered anatomy who develop biliary disease create a unique diagnostic and therapeutic challenge. Conventional ERCP is impossible, while alternative options such as laparoscopic-assisted or balloon-assisted ERCP are technically challenging. Percutaneous trans-hepatic biliary drainage requires repeated procedures and the nuisance of an external drainage catheter. After multidisciplinary discussions with obstetrics, hepatobiliary surgery, and interventional radiology, treatment options were reviewed with the patient. The primary goal was to limit radiation and anesthetic exposure during the remainder of her pregnancy. Given the need for repetitive interventions when considering balloon-assisted ERCP and percutaneous trans-hepatic biliary drainage, the decision was made to perform EUS-guided hepatico-gastrostomy, which allowed for a single procedure to treat hepatico-jejunostomy stricture and allow biliary drainage in a minimally invasive fashion until the patient was postpartum. Under endosonographic guidance, a dilated peripheral biliary radical was identified and punctured using a 19-gauge needle. A cholangiogram demonstrated intrahepatic bile duct dilation and evidence of a hepatico-jejunostomy stricture. A long guide wire was advanced through the left hepatic duct and across the hepatico-jejunostomy. The hepatico-gastrostomy tract and the hepatico-jejunostomy stricture were both dilated using a 3-4-5 French dilating catheter and 6-mm biliary dilating balloon. The hepatico-gastrostomy was created with two overlapping fully covered self-expandable metal stents, a 10-mm by 10-cm long and 10-mm by 6-cm long metal stent. Two 7-French by 7-cm double plastic pigtail stents were then deployed coaxially through the fully covered self-expandable metal stent across the hepatico-jejunostomy stricture and terminating in the gastric lumen. The patient did well post-procedure and eventually delivered her child uneventfully. At subsequent transmutal ERCP, four months later, all indwelling stents were removed. Cholangiogram was notable for persistent hepatico-jejunostomy stenosis. There was moderate resistance with a retrograde 9-mm balloon sweep. The hepatico-jejunostomy was dilated with a 6-mm and 8-mm dilating balloon. Four 7-French by 12-cm double pigtail plastic stents were placed across the hepatico-gastrostomy and hepatico-jejunostomy. Final transmutal ERCP was notable for free flow of contrast across the hepatico-jejunostomy and no resistance with 9-mm extraction balloon pull-through. The patient remains well two months post-procedure. EUS-guided hepatico-gastrostomy permitted endoscopic therapy of the hepatico-jejunostomy stricture in a minimally invasive fashion. Endoscopic EUS can be a powerful tool in the management of patients with altered GI anatomy and pancreatic obiliary disease. EUS-guided hepatico-gastrostomy for biliary drainage in a pregnant patient with altered GI anatomy was technically feasible and safe in our case.

pregnant patient

altered anatomy

biliary disease

EUS-guided hepatico-gastrostomy

hepatico-jejunostomy stricture