Immediate puncture of a dislocated partially covered self-expandable metal stent in endoscopic ultrasound-guided hepaticogastrostomy for prevention of bile leakage

Abstract

A 69-year-old woman with complex hilar strictures due to unresectable gallbladder cancer was admitted for plastic stents obstruction. Considering duodenal invasion, conversion to endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with bridging stenting after temporary naso-biliary drainage was planned.¹ After puncturing B2 with a 19 G needle (Fig. 1a), two 0.025 inch guidewires were inserted into B8 and B6 using a double-lumen catheter. Two uncovered self-expandable metal stents (SEMS) were placed in both branches in partially stent-in-stent configuration. Finally, an 8 mm × 12 cm partially covered SEMS (Spring Stopper; Taewoong Medical, Seoul, Korea) with a 15 mm uncovered portion at the distal end was placed in B2 as a transluminal drainage/anastomosis stent (T-DAS). However, the T-DAS was accidentally moved toward the stomach because the tip of the inner catheter was stuck during removal.² Since the uncovered portion was suspected to be exposed to the abdominal cavity (Fig. 1b), there was concern for persistent bile leakage. Coaxial insertion of a fully-covered SEMS (HANAROSTENT Benefit; M.I.Tech, Seoul, Korea) to seal the uncovered portion failed and the guidewire was dislodged. The T-DAS within the liver parenchyma was then punctured with the 19 G needle (Fig. 1c), followed by manipulation of the 0.025 inch guidewire to bring it out of the distal end of the T-DAS into the bile duct (Fig. 1d). The HANAROSTENT Benefit was successfully placed as a second T-DAS after passing through the mesh of the first T-DAS and stopped bile leakage by completely covering the uncovered portion of the first T-DAS in the bile duct (Fig. 2, Video S1). Although computed tomography on the next day showed fluoroscopic markers at the end of the uncovered portion of the first T-DAS were outside of the liver, the clinical course was uneventful. For dislocation of a partially covered SEMS in EUS-HGS, this rescue method could be useful when coaxial fully covered SEMS insertion fails.

Authors declare no conflict of interest for this article.