EUS-RESCUING INTERNALLY PLACED SEMS DURING ENDOSCOPIC ULTRASOUND ASSISTED HEPATICOGASTROSTOMY

Video Transcription

Rescuing internally-placed SEMS during endoscopic ultrasound-assisted hepatico-gastrostomy. Primary Author Sandeep Laktakia  Additional Authors Radev Inowaloo, Aniruddha Pratap Singh, Radhika Chauhan, D. Nageshwar  A 60-year-old male with thylark-cholangiocarcinoma presented with cholangitis. He underwent ERCP with uncovered biliary self-expandable metal stent placed in the right hepatic duct  three months ago. Imaging confirmed significant left intra-hepatic biliary radical dilatation. ERCP failed to drain the dilated left hepatic duct system.  U.S.-guided hepatico-gastrostomy was planned. Scott's fluoroscopic image showing biliary SEMS in the right hepatic system. Endoscopic ultrasound was done.  Significant left intra-hepatic biliary radical dilatation was noted. Segment 3 duct was punctured using a 19-gauge needle.  Bile was aspirated and contrast was injected to delineate the anatomy.  Guide wire was then passed into the biliary system which went into the segment 2.  The tract was dilated using over-the-wire 6-french systatome. While deploying a partially covered metal stent under endoscopic view, it was realized  that the external end of the stent was outside the gastric valve.  However, the internal end was in the left hepatic duct. Guide wire was kept in the same position and second fully covered metal SEMS was telescoped  over the wire inside the first stent and was deployed inside the gastric lumen.  This salvaged a severe adverse event that can be associated with EUS-HGS procedure.  Clinical Implications EUS-Guided Hepaticogastrostomy is a fallback option for biliary drainage when ERCP is not feasible or failed.  EUS-HGS is skillfully demanding and is associated with adverse events including internal deployment of the stent.  Keeping the guide wire in place throughout the procedure would help salvage maldeployment of the stent.  In our patient, the guide wire was useful in placing a fully covered SEMS into the maldeployed stent which helped salvage this adverse event.  EUS-HGS is a useful rescue procedure for biliary drainage. Always having the guide wire in place is the key to prevent adverse events like peritonitis.

Video Summary

This video summarizes a case study conducted by Sandeep Laktakia and his team on rescuing internally placed self-expandable metal stents (SEMS) during endoscopic ultrasound-assisted hepatico-gastrostomy. The patient, a 60-year-old male with thylark-cholangiocarcinoma, had undergone ERCP with an uncovered biliary SEMS three months prior but developed cholangitis. ERCP failed to drain the left hepatic duct system, so U.S.-guided hepatico-gastrostomy was planned. The procedure involved puncturing the segment 3 duct, injecting contrast, and dilating the tract. While deploying a partially covered metal stent, it was found that its external end was outside the gastric valve but the internal end was in the left hepatic duct. By keeping the guide wire in place, a second fully covered SEMS was telescoped over it and deployed inside the gastric lumen, salvaging the adverse event. The video highlights the clinical implications of EUS-HGS as a fallback option for biliary drainage and emphasizes the importance of keeping the guide wire in place to prevent adverse events.

Asset Subtitle

Honorable Mention

Keywords

case study

self-expandable metal stents

endoscopic ultrasound-assisted hepatico-gastrostomy

cholangiocarcinoma

biliary drainage