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IMAGES AND VIDEOS
Year : 2019  |  Volume : 8  |  Issue : 5  |  Page : 352-353

Antegrade stenting combined with hepaticogastrostomy using a 5.4-Fr novel ultra-slim metallic stent and dedicated stent under EUS guidance (with video)


Division of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki; Department of Gastroenterology and Hepatology, Division of Endoscopy, Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan

Date of Submission26-Dec-2018
Date of Acceptance05-Jun-2019
Date of Web Publication22-Aug-2019

Correspondence Address:
Dr. Hiroshi Kawakami
Division of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki; Department of Gastroenterology and Hepatology, Division of Endoscopy, Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_40_19

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How to cite this article:
Kawakami H, Kubota Y, Ban T. Antegrade stenting combined with hepaticogastrostomy using a 5.4-Fr novel ultra-slim metallic stent and dedicated stent under EUS guidance (with video). Endosc Ultrasound 2019;8:352-3

How to cite this URL:
Kawakami H, Kubota Y, Ban T. Antegrade stenting combined with hepaticogastrostomy using a 5.4-Fr novel ultra-slim metallic stent and dedicated stent under EUS guidance (with video). Endosc Ultrasound [serial online] 2019 [cited 2019 Dec 12];8:352-3. Available from: http://www.eusjournal.com/text.asp?2019/8/5/352/264239



EUS-guided biliary drainage (EUS-BD) has been developed for failed or difficult ERCP. In particular, EUS-guided antegrade stenting (EUS-AGS) combined with EUS-guided hepaticogastrostomy (EUS-HGS) is suitable for gastric outlet obstruction (GOO) or surgically altered anatomy.[1] However, EUS-BD requires fistula dilation before stenting and carries the potential risk of bile leak from the fistula. Herein, we present the case of a patient who underwent EUS-HGS combined with EUS-AGS for unresectable duodenal cancer, using novel ultra-slim devices.

A 78-year-old woman presented with a 1-week history of vomiting and obstructive jaundice. Esophagogastroduodenoscopy revealed advanced duodenal cancer and GOO [Figure 1]a. Contrast-enhanced computed tomography showed distal bile duct obstruction caused by the duodenal cancer [Figure 1]b. We performed EUS-AGS combined with EUS-HGS for BD. First, a B3 branch was punctured using a 19G needle, and a 0.025“ stiff guidewire (VisiGlide 2, Olympus Inc. Tokyo, Japan) was placed [Video 1]. Next, a tapered ERCP catheter was used to dilate the fistula following successful passage of the guidewire through the distal bile duct stricture. Then, EUS-AGS was performed using a novel ultra-slim uncovered self-expandable metal stent (ZEOSTENT V; 5.4-Fr delivery system, 10-mm diameter; Zeon Medical Inc. Tokyo, Japan) [Figure 2]a and[Figure 2]b. Finally, a novel 7-Fr plastic stent (TYPE-IT stent; Gadelius Medical Co. Ltd., Tokyo, Japan) [Video 1] was placed to create an EUS-HGS without any complications [[Figure 2]c and Video 1].
Figure 1: (a) Endoscopic image showing duodenal cancer and gastric outlet obstruction. (b) Radiograph showing distal bile duct obstruction caused by duodenal cancer

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Figure 2: (a) Tips and delivery systems of various ultra-slim self-expandable uncovered metallic stents. Top: ZEOSTENT V (Zeon Medical Inc. Tokyo, Japan; 5.4-Fr maximum diameter), the drawer second: BileRush Selective (Piolax Medical Devices, Yokohama, Japan; 5.7-Fr maximum diameter), the drawer third: Epic™ Biliary Stent (Boston Scientific Japan, Tokyo, Japan, 6.0-Fr maximum diameter), bottom: Zilver635 Biliary Metallic Stent (Cook Medical, Bloomington, IN, USA, 6.0-Fr maximum diameter). (b) Comparison of tips over a 0.025“ guidewire with various ultra-slim self-expandable uncovered metallic stents (left side in each: ZEOSTENT V). (a) (left) BileRush Selective (maximum diameter of 5.7 Fr, Piolax Medical Devices, Yokohama, Japan), (b) (middle) ZILVER635 (maximum diameter of 6.0 Fr, Cook Medical, Bloomington, IN, USA), (c) (right) Epic™ Biliary Stent (maximum diameter of 6.0 Fr, Boston Scientific Japan, Tokyo, Japan). (c) Radiograph showing EUS-guided antegrade stenting with a novel 5.4-Fr uncovered self-expandable metallic stent combined with EUS-guided hepaticogastrostomy with a novel dedicated 7.0-Fr plastic stent

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Bile leaks are a concern during EUS-BD, and they can be minimized by avoiding unnecessary dilation and reducing device exchanges. Ultra-slim devices (7-Fr or less) are suitable as they can facilitate the procedure.[1],[2] Ultra-slim devices also allow for relatively easy stent deployment with less frequent microdamage to the echoendoscope. Although a consensus cannot be reached in EUS-BD, EUS-AGS combined with EUS-HGS using ultra-slim devices is safe. Thus, the development of uncovered metallic stents with ultra-slim delivery is a key for successful procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kawakami H, Kubota Y. Endoscopic ultrasonography-guided antegrade stenting combined with hepaticogastrostomy/hepaticojejunostomy using ultraslim instruments. Endoscop y 2017;49:E88-9.  Back to cited text no. 1
    
2.
Kawakami H, Kubota Y. Novel wire-guided fine-gauge bougie dilator for transpapillary or endoscopic ultrasonography-guided biliary drainage. Endoscopy 2017;49:E75-7.  Back to cited text no. 2
    


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