Ahmed M. Elmeligui, MBBCh, MD1, Ameya A. Deshmukh, BA2, Javier Tejedor-Tejada, MD3, Enad Dawod, MD4, Jose Nieto, DO, FACG5; 1Kasr Alainy Hospital / Cairo University, Cairo, Al Jizah, Egypt; 2Midwestern University - CCOM, Downers Grove, IL; 3Hospital Universitario Rio Hortega, Valladolid, Castilla y Leon, Spain; 4New York-Presbyterian/Weill Cornell Medical Center, New York City, NY; 5Borland Groover Clinic, Jacksonville, FL
Introduction: Palliative endoscopic biliary stenting is widely performed in patients with nonresectable malignant biliary obstruction through transpapillary approach using ERCP. When ERCP is not feasible, percutaneous transhepatic biliary drainage (PTBD) or surgical bypass procedures are performed but these are associated with increased morbidity and mortality. EUS-guided hepaticogastrostomy (HG) for intrahepatic biliary drainage combined with cholecystoduedenostomy (CCD) using lumen apposing metal stent (LAMS) was chosen.
Methods: An 84-year-old female known to have metastatic breast cancer who presented with worsening obstructive jaundice. Past medical and surgical history includes hypertension, dyslipidemia, CAD, CABG, Right breast cancer Lumpectomy and radiation. Total bilirubin was 17 mg/dl, direct bilirubin was 15 mg/dl, ALT and AST were mildly elevated. CT abdomen displayed a large right hepatic lobe mass extending to the hepatic hilum resulting in proximal common bile duct obstruction and severe intrahepatic biliary dilation.
The markedly dilated intrahepatic bile ducts were displayed on EUS in the stomach. EUS guided contrast injection into left hepatic bile duct was performed using a 19G FNA needle. EUS cholangiogram revealed markedly dilated right and left hepatic ducts with an attenuated common bile duct and obstructed cystic duct. Then, the echoendoscope was passed into the duodenum and distended gallbladder with multiple stones was visualized. A 10 mm LAMS was inserted using an electric enhanced catheter which subsequently passed into the gallbladder and the LAMS was then deployed. The measured distance between the stomach wall and the left intrahepatic bile duct was 8 mm. Another single stage LAMS was deployed under endosonographic guidance and a track between the lumen of the stomach and left intrahepatic bile duct was created. EUS cholangiogram revealed complete drainage of the left branch and partial drainage of the right branch of the intrahepatic bile ducts. A 0.035 guide wire was passed through the LAMS then a plastic stent was inserted to ensure proper drainage of the biliary system and to prevent food impaction into the 10 mm LAMS. EUS cholangiogram revealed near complete drainage of the obstructed biliary system.
Follow up abdominal CT revealed resolution of intrahepatic biliary dilation. Discussion: We have demonstrated the safety and efficacy of the EUS-guided combined HG biliary drainage and CCD procedure using LAMS in patients with malignant bile duct obstruction.
CT abdomen with contrast showing: (1) Large right lobe hepatic mass (Black arrow) compressing the common bile duct and cystic duct. (2) Dilated intrahepatic bile ducts (Black arrow heads).
EUS cholangiogram showing markedly dilated right and left intrahepatic ducts (Black arrows), Distal CBD stricture (Black arrow heads) and obstructed cystic duct (White arrow).
CT scan showing boths biliary stents and both AXIOS stents.
Disclosures: Ahmed Elmeligui indicated no relevant financial relationships. Ameya Deshmukh indicated no relevant financial relationships. Javier Tejedor-Tejada indicated no relevant financial relationships. Enad Dawod indicated no relevant financial relationships. Jose Nieto: Boston Scientific – Consultant. ERBE – Consultant.