EUS guided hepaticogastrostomy for management of cholangitis, hepatolithiasis, and anastomotic stricture after Roux-en-Y hepaticogenostomy. These are our disclosures. Endoscopic retrograde cholangiography can be technically challenging to perform with traditional duodenoscopes in patients with surgically altered gastrointestinal anatomy. Historically, patients with SAGA have required device-assisted enteroscopy, percutaneous transhepatic biliary drainage, or invasive surgical procedures for management of biliary disease. Endoscopic ultrasound guided hepaticogastrostomy is a novel endoscopic technique that provides alternate access to the biliary tree. A 43-year-old female with prior laparoscopic cholecystectomy, complicated by bile duct injury, status post Roux-en-Y hepaticogenostomy, presented with obstructive jaundice and cholangitis. Labs on admission showed a total bilirubin of 10.2 with elevated AST, ALT, and alkaline phosphatase. MRCP showed three stones at the confluence of the right and left hepatic ducts, measuring up to 8 millimeters in diameter. Moderate intrahepatic biliary ductal dilation was noted. After discussion with the patient, a decision was made to proceed with EUS-guided HG. Step 1, EUS-guided hepaticogastrostomy for biliary drainage for cholangitis. The left lobe of the liver was examined from the stomach. A dilated biliary radical in segment 3 was identified and punctured using a 19-gauge FNA needle. Contrast was injected, resulting in opacification of the left intrahepatic biliary tree. Further injection of contrast in the left hepatic duct showed three filling defects consistent with stones. Of note, there was no flow of contrast past the hepaticogenostomy anastomosis into the small bowel. This was suggestive of a high-grade HG anastomotic stricture. A biliary dilating balloon measuring 4 millimeters in diameter and 4 centimeters in length was then advanced via the HG tract. Segmental dilation of the tract was performed to facilitate stent placement. An 8 millimeter in diameter and 8 centimeter in length fully covered metal stent was placed across the hepaticogastrostomy tract. Post-deployment, it was noted that the stent length in the stomach was less than 2 centimeters. A second fully covered metal stent was then placed through the existing metal stent with a greater length deployed in the stomach to prevent stent dislodgement and migration in the peritoneal cavity. Patient was discharged home the following day without any complications. Follow-up labs one week post-procedure showed resolution of her transaminitis and normalization of bilirubin. She was scheduled for an ERC via the HG tract in four weeks for definitive management of intrapathic stones and HG anastomotic stricture. Step 2. ERC with cholangioscopy, electrohydraulic lithotripsy, and stricture dilation via the HG tract. Using a sphincter dome preloaded with a 0.025 inch diameter guide wire, the left hepatic duct was cannulated through the existing metal stent. The sphincter dome was then advanced over the guide wire into the left ductal system. After a gentle manipulation, the guide wire could be negotiated past the hepaticogenostomy anastomotic stricture into the small bowel. Cholangiograms showed three filling defects consistent with stones proximal to the HG anastomotic stricture. A decision was made to dilate the stricture to facilitate antigrid removal of intrapathic stones. Attempts to advance the sphincter dome past the stricture into the small bowel were unsuccessful. A 3.5 French tapered tip catheter was subsequently used to negotiate the stricture. However, this was unsuccessful despite multiple attempts. The HG metal stents were subsequently removed using a rat tooth forceps. This was done to facilitate cholangioscopy, electrohydraulic lithotripsy, and retrograde stone removal. With the wire deeply positioned in the small bowel, the digital cholangioscope was advanced over the guide wire and along the duct until the stone was visualized. Wire was then removed and an EHL probe was advanced and positioned in close proximity to the stones. Sequential pulses of EHL were then delivered using a power of 70 watts until stones were fragmented. During stone fragmentation, the stenotic hepatic adjustinostomy anastomosis was visualized. Multiple balloon sweeps of the left hepatic duct were performed using an 8.5 millimeter stone extraction balloon and stone fragments were successfully removed. An occlusion cholangiogram was subsequently obtained and did not show any residual filling defects. Next, a 3.5 French tapered tip catheter was advanced over the guide wire and negotiated past the stricture into the small bowel. The stricture was dilated to 7 French using graduated dilation catheter. A fully covered metal stent was placed across the HG tract to establish drainage. A 7 French by 15 centimeter double pigtail berry stent was in place through the HG metal stent with the proximal end past the anastomotic stricture into the small bowel and the distal end in the stomach. Christine was discharged home same day post procedure without any complications. She's scheduled for follow-up ERC in 6 weeks for ongoing management of HG anastomotic stricture. EUS-HG provides a safe alternative to surgery and PTBD in patients with older GI anatomy and biliary pathology. Once the EUS-HG tract is established, it can serve as a port to the biliary tree, thus allowing advanced endoscopic procedures to be performed effectively.

endoscopic ultrasound-guided hepaticogastrostomy

obstructive jaundice

cholangitis

laparoscopic cholecystectomy

bile duct injury