Abstract
BACKGROUND: Endoscopic ultrasound guided hepatogastrostomy (EUS-HGS) is a popular approach to EUS-biliary drainage especially in the setting of concomitant gastric outlet obstruction. The main disadvantage of EUS-HGS is that it requires a dilated biliary system AIMS: A case report (with video) describing the first conversion of a percutaneous transhepatic biliary drain (PTBD) into an HGS in a non-dilated biliary system using EUS and interventional radiology (IR) techniques. METHODS: A 43-year old male underwent a staged R0 hepatic resection for colon cancer metastases, during which the common bile duct was fully transected. Bilateral PTBD were placed. Definitive stable drainage was required to allow adjuvant chemotherapy. The surgical option was a Roux-en-Y hepatico-jejunostomy. HGS was chosen as less invasive option allowing faster recovery and earlier initiation of chemo RESULTS: Under EUS guidance, a non-dilated segment II bile duct was punctured with a 19-gauge needle; however, given the small ductal caliber wire passage was not possible. Via the PTBD, 2 occlusive balloons were inserted into the target duct, with one central and one peripheral to the target puncture site. Saline was infused between the balloons, dilating the isolated bile duct segment. This eased the duct puncture and passage of an 0.035-inch guidewire. The wire; however, traveled peripherally in the bile ducts but was successfully grasped with a loop-snare (via PTBD access) and pulled out the PTBD track. With control of both ends of the wire, the hepatogastrostomy tract was easily dilated to 6 mm with a balloon inserted by PTBD. During tract dilation, A 10 mmx80 mm partially covered self-expandable metal stent was simultaneously loaded through the endoscope and advanced through the HGS tract immediately following deflation of the balloon thereby minimizing the time between dilation and stent insertion, to reduce bile leak. The stent was then successfully deployed with excellent spontaneous drainage of contrast. The patient was discharged 4 days later following check cholangiogram, normalization of bilirubin and removal of the PTBD. He was pain free with no evidence of bile leak CONCLUSIONS: We report the first successful conversion of PTBD to HGS using EUS and IR techniques in a non-dilated biliary system. Collaboration between endoscopists and IR can enhance the safety and feasability FUNDING AGENCIES: None