GASTROENTEROLOGY IN MOTION Ralf Kiesslich and Thomas D. Wang, Section Editors
EUS-Guided Antegrade Balloon Dilation From Right Hepatic Duct Combined With Retrograde Rendezvous Stent Placement Takeshi Ogura,1 Saori Onda,1 Tatsushi Sano,1 Wataru Takagi,1 Masayuki Kitano,2 Daisuke Masuda,1 Akira Imoto,1 Shinya Fukunishi,1 and Kazuhide Higuchi1 1
Second Department of Internal Medicine, Osaka Medical College, Osaka, 2Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
Scan the quick response (QR) code to the left with your mobile device to watch this article’s video abstract and others. Don’t have a QR code reader? Get one by searching ‘QR Scanner’ in your mobile device’s app store.
V
arious interventional endoscopic ultrasound (EUS) procedures for biliary drainage (BD) have been reported, such as EUS-guided choledochoduodenostomy,1 EUS-guided hepaticogastrostoy,2 and the rendezvous technique (RV).3 However, if hepatic hilar or isolated right intrahepatic biliary duct (IHBD) stricture occurs, EUS-BD or EUS-RV for the right IHBD might be challenging, because the left IHBD or common bile duct has generally been chosen as puncture site to access the biliary tract. In addition, the technical success rate of EUS-RV is not particularly high.4 EUS-guided hepaticoduodenostomy for isolated right IHBD has been reported recently.5,6 Although this method has clinical impact as salvage BD for selected cases, such as in advanced malignancy, the clinical course is unclear because of a lack of long-term follow-up. Antegrade stenting from right IHBD also carries a possibility of bile leakage because of the need to dilate the fistula. These procedures should, therefore, be selected under strict criteria, such as in patients with limited prognosis, and may not be suitable for benign disease. We report herein a case of EUS-guided antegrade balloon dilation for benign right IHBD stricture using a right hepatic bile duct route.
Description of Technology To visualize the right hepatic bile duct, an echoendoscope (GF-UCT260; Olympus Optical, Tokyo, Japan) is advanced into the duodenal bulb or antrum; then, the echoendoscope was rotated counterclockwise. Using a 19G fine needle aspiration (FNA) needle (Sono Tip Pro Control 19G; Medi-Globe, Rosenheim, Germany), the right hepatic bile duct is punctured. At this time, the choice of a bile duct near the hepatic hilum as the puncture site is
important, because the guidewire needs to be advanced to the common bile duct. Next, the guidewire (0.025-inch, angle-type tip, VisiGlide; Olympus Medical Systems, Tokyo, Japan) is inserted into the bile duct. If advancing the guidewire into the common bile duct across the stricture site is difficult, we insert an endoscopic retrograde cholangiopancreatography (ERCP) catheter (MTW Endoskopie, Düsseldorf, Germany). During attempted stricture passage, an experienced assistant handles the guidewire. To advance the guidewire into the common bile duct, pushing the guidewire with torque near the stricture site is important. After we successfully place the guidewire into the common bile duct across the stricture site, we insert the balloon catheter (8 mm, Hurricane balloon catheter; Boston Scientific Japan, Tokyo, Japan). After dilating the stricture, we exchange the ERCP scope. We then insert the ERCP catheter and guidewire into the intrahepatic bile duct across the stricture site using the guidewire as a landmark. Finally, an endoscopic nasal BD tube or stent can be placed. If the EUS-RV technique fails, bile leakage might occur from the puncture site. On the other hand, our method may be safer and easier than EUS-RV, because stricture is resolved by antegrade balloon dilation.
Video Description A 71-year-old man underwent chemotherapy and radiotherapy for tumor embolus of the portal vein owing to hepatocellular carcinoma. He was admitted to our hospital because of right IHBD dilatation with cholangitis (Figure 1A). Liver testing showed aspartate aminotransferase, 222 IU/L; alanine aminotransferase, 198 IU/L; and bilirubin, 2.9 mg/dL. We attributed the dilatation to radiotherapy based on the results of contrast-enhanced EUS and FNA. We therefore tried BD for right IHBD. The video shows technical tips of antegrade balloon dilation
© 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.03.007
Gastroenterology 2015;148:901–903
GASTROENTEROLOGY IN MOTION
Figure 1. (A) CT shows isolated right bile duct dilation, and no tumor is evident. (B) We puncture the right intrahepatic bile duct from the duodenal bulb using a 19-G FNA needle.
combined with retrograde rendezvous stent placement (video speed, 1.5). First, we performed ERCP. However, we could not advance the guidewire into the right IHBD. We therefore decided to access the right IHBD under EUS guidance. We advanced a convex echoendoscope into the duodenum bulb. Using counterclockwise rotation, the right IHBD was visualized. The right IHBD was punctured using a 19-G FNA needle (Figure 1B). Next, we aspirated bile juice and injected contrast medium. Stricture of the right IHBD was created; then, an 0.025-inch stiff, angle-type guidewire (VisiGlide; Olympus Medical Systems) was inserted, and the ERCP catheter was exchanged from 19-G FNA needle. We successfully advanced the guidewire into the duodenum across the right IHBD stricture (Figure 2A). We first performed antegrade biliary dilation using a balloon dilation catheter (Figure 2B). Next, we changed the ERCP scope from an echoendoscope; then, we inserted the cannula into the common bile duct. Using the guidewire as a landmark, we successfully advanced the guidewire into the right
Figure 2. (A) We successfully advance the guidewire into the common bile duct across the biliary stricture. (B) We perform antegrade balloon dilation using an 8-mm balloon catheter. (C) To avoid bile leakage from the fistula, we exchange the ERCP scope, and successfully perform stent placement under ERCP guidance.
902
IHBD. Finally, we performed 7-Fr plastic biliary stent placement (Figure 2C). No adverse events were seen in association this procedure.
Take Home Message EUS-guided antegrade balloon dilation from a right hepatic bile duct route has clinical impact, but if a stricture site is present in the peripheral bile duct, this method may not be indicated because of difficulty advancing the guidewire into the common bile duct. Additional cases are needed to evaluate this technique.
Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www.gastrojournal.org, and at http://dx.doi.org/10.1053/ j.gastro.2015.03.007.
GASTROENTEROLOGY IN MOTION References 1.
2.
3.
4.
Hara K, Yamao K, Hijioka S, et al. Prospective clinical study of endoscopic ultrasound-guided choledochoduodenostomy with direct metallic stent placement using a forwardviewing echoendoscope. Endoscopy 2013;45:392–396. Paik WH, Park do H, Choi JH, et al. Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy. Gastrointest Endosc 2014;20:5051–5059. Isayama H, Nakai Y, Kawakubo K, et al. The endoscopic ultrasonography-guided rendezvous technique for biliary cannulation: a technical review. J Hepatobiliary Pancreat Sci 2013;20:413–420. Itoi T, Isayama H, Sofuni A, et al. Stent selection and tips on placement technique of EUS-guided biliary drainage:
5.
6.
transduodenal and transgastric stenting. J Hepatobiliary Pancreat Sci 2011;18:664–672. Park SJ, Choi JH, Park do H, et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc 2013;78:374–380. Ogura T, Sano S, Onda S, et al. Endoscopic ultrasoundguided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy 2015;47:72–75.
Reprint requests Address requests for reprints to: Takeshi Ogura, Second Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka 569-8686, Japan. e-mail: [email protected]. Conflicts of interest The authors disclose no conflicts.
903
EUS-Guided Antegrade Balloon Dilation From Right Hepatic Duct Combined With Retrograde Rendezvous Stent Placement Takeshi Ogura,1 Saori Onda,1 Tatsushi Sano,1 Wataru Takagi,1 Masayuki Kitano,2 Daisuke Masuda,1 Akira Imoto,1 Shinya Fukunishi,1 and Kazuhide Higuchi1 1
Second Department of Internal Medicine, Osaka Medical College, Osaka, 2Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
Scan the quick response (QR) code to the left with your mobile device to watch this article’s video abstract and others. Don’t have a QR code reader? Get one by searching ‘QR Scanner’ in your mobile device’s app store.
V
arious interventional endoscopic ultrasound (EUS) procedures for biliary drainage (BD) have been reported, such as EUS-guided choledochoduodenostomy,1 EUS-guided hepaticogastrostoy,2 and the rendezvous technique (RV).3 However, if hepatic hilar or isolated right intrahepatic biliary duct (IHBD) stricture occurs, EUS-BD or EUS-RV for the right IHBD might be challenging, because the left IHBD or common bile duct has generally been chosen as puncture site to access the biliary tract. In addition, the technical success rate of EUS-RV is not particularly high.4 EUS-guided hepaticoduodenostomy for isolated right IHBD has been reported recently.5,6 Although this method has clinical impact as salvage BD for selected cases, such as in advanced malignancy, the clinical course is unclear because of a lack of long-term follow-up. Antegrade stenting from right IHBD also carries a possibility of bile leakage because of the need to dilate the fistula. These procedures should, therefore, be selected under strict criteria, such as in patients with limited prognosis, and may not be suitable for benign disease. We report herein a case of EUS-guided antegrade balloon dilation for benign right IHBD stricture using a right hepatic bile duct route.
Description of Technology To visualize the right hepatic bile duct, an echoendoscope (GF-UCT260; Olympus Optical, Tokyo, Japan) is advanced into the duodenal bulb or antrum; then, the echoendoscope was rotated counterclockwise. Using a 19G fine needle aspiration (FNA) needle (Sono Tip Pro Control 19G; Medi-Globe, Rosenheim, Germany), the right hepatic bile duct is punctured. At this time, the choice of a bile duct near the hepatic hilum as the puncture site is
important, because the guidewire needs to be advanced to the common bile duct. Next, the guidewire (0.025-inch, angle-type tip, VisiGlide; Olympus Medical Systems, Tokyo, Japan) is inserted into the bile duct. If advancing the guidewire into the common bile duct across the stricture site is difficult, we insert an endoscopic retrograde cholangiopancreatography (ERCP) catheter (MTW Endoskopie, Düsseldorf, Germany). During attempted stricture passage, an experienced assistant handles the guidewire. To advance the guidewire into the common bile duct, pushing the guidewire with torque near the stricture site is important. After we successfully place the guidewire into the common bile duct across the stricture site, we insert the balloon catheter (8 mm, Hurricane balloon catheter; Boston Scientific Japan, Tokyo, Japan). After dilating the stricture, we exchange the ERCP scope. We then insert the ERCP catheter and guidewire into the intrahepatic bile duct across the stricture site using the guidewire as a landmark. Finally, an endoscopic nasal BD tube or stent can be placed. If the EUS-RV technique fails, bile leakage might occur from the puncture site. On the other hand, our method may be safer and easier than EUS-RV, because stricture is resolved by antegrade balloon dilation.
Video Description A 71-year-old man underwent chemotherapy and radiotherapy for tumor embolus of the portal vein owing to hepatocellular carcinoma. He was admitted to our hospital because of right IHBD dilatation with cholangitis (Figure 1A). Liver testing showed aspartate aminotransferase, 222 IU/L; alanine aminotransferase, 198 IU/L; and bilirubin, 2.9 mg/dL. We attributed the dilatation to radiotherapy based on the results of contrast-enhanced EUS and FNA. We therefore tried BD for right IHBD. The video shows technical tips of antegrade balloon dilation
© 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.03.007
Gastroenterology 2015;148:901–903
GASTROENTEROLOGY IN MOTION
Figure 1. (A) CT shows isolated right bile duct dilation, and no tumor is evident. (B) We puncture the right intrahepatic bile duct from the duodenal bulb using a 19-G FNA needle.
combined with retrograde rendezvous stent placement (video speed, 1.5). First, we performed ERCP. However, we could not advance the guidewire into the right IHBD. We therefore decided to access the right IHBD under EUS guidance. We advanced a convex echoendoscope into the duodenum bulb. Using counterclockwise rotation, the right IHBD was visualized. The right IHBD was punctured using a 19-G FNA needle (Figure 1B). Next, we aspirated bile juice and injected contrast medium. Stricture of the right IHBD was created; then, an 0.025-inch stiff, angle-type guidewire (VisiGlide; Olympus Medical Systems) was inserted, and the ERCP catheter was exchanged from 19-G FNA needle. We successfully advanced the guidewire into the duodenum across the right IHBD stricture (Figure 2A). We first performed antegrade biliary dilation using a balloon dilation catheter (Figure 2B). Next, we changed the ERCP scope from an echoendoscope; then, we inserted the cannula into the common bile duct. Using the guidewire as a landmark, we successfully advanced the guidewire into the right
Figure 2. (A) We successfully advance the guidewire into the common bile duct across the biliary stricture. (B) We perform antegrade balloon dilation using an 8-mm balloon catheter. (C) To avoid bile leakage from the fistula, we exchange the ERCP scope, and successfully perform stent placement under ERCP guidance.
902
IHBD. Finally, we performed 7-Fr plastic biliary stent placement (Figure 2C). No adverse events were seen in association this procedure.
Take Home Message EUS-guided antegrade balloon dilation from a right hepatic bile duct route has clinical impact, but if a stricture site is present in the peripheral bile duct, this method may not be indicated because of difficulty advancing the guidewire into the common bile duct. Additional cases are needed to evaluate this technique.
Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www.gastrojournal.org, and at http://dx.doi.org/10.1053/ j.gastro.2015.03.007.
GASTROENTEROLOGY IN MOTION References 1.
2.
3.
4.
Hara K, Yamao K, Hijioka S, et al. Prospective clinical study of endoscopic ultrasound-guided choledochoduodenostomy with direct metallic stent placement using a forwardviewing echoendoscope. Endoscopy 2013;45:392–396. Paik WH, Park do H, Choi JH, et al. Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy. Gastrointest Endosc 2014;20:5051–5059. Isayama H, Nakai Y, Kawakubo K, et al. The endoscopic ultrasonography-guided rendezvous technique for biliary cannulation: a technical review. J Hepatobiliary Pancreat Sci 2013;20:413–420. Itoi T, Isayama H, Sofuni A, et al. Stent selection and tips on placement technique of EUS-guided biliary drainage:
5.
6.
transduodenal and transgastric stenting. J Hepatobiliary Pancreat Sci 2011;18:664–672. Park SJ, Choi JH, Park do H, et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc 2013;78:374–380. Ogura T, Sano S, Onda S, et al. Endoscopic ultrasoundguided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy 2015;47:72–75.
Reprint requests Address requests for reprints to: Takeshi Ogura, Second Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka 569-8686, Japan. e-mail: [email protected]. Conflicts of interest The authors disclose no conflicts.
903
