• Users Online:717
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2019  |  Volume : 8  |  Issue : 7  |  Page : 44-49

Outcomes and limitations: EUS-guided hepaticogastrostomy

1 Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
2 Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea

Date of Submission11-Jun-2019
Date of Acceptance08-Jul-2019
Date of Web Publication28-Nov-2019

Correspondence Address:
Dr. Do Hyun Park
Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-gu, 05505, Seoul
South Korea
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_51_19

Rights and Permissions

One of the major roles of interventional EUS is biliary decompression as an alternative to ERCP or percutaneous transhepatic biliary drainage. Among EUS-guided biliary drainage, EUS-guided hepaticogastrostomy with transmural stenting (EUS-HGS) may be the most promising procedure since this procedure can overcome the limitation of ERCP. However, EUS-HGS has disadvantages, and the safety issue is still not resolved. In this review, the clinical outcomes and limitations of EUS-HGS will be discussed.

Keywords: Adverse event, EUS, hepaticogastrostomy

How to cite this article:
Paik WH, Park DH. Outcomes and limitations: EUS-guided hepaticogastrostomy. Endosc Ultrasound 2019;8, Suppl S1:44-9

How to cite this URL:
Paik WH, Park DH. Outcomes and limitations: EUS-guided hepaticogastrostomy. Endosc Ultrasound [serial online] 2019 [cited 2020 Aug 5];8, Suppl S1:44-9. Available from: http://www.eusjournal.com/text.asp?2019/8/7/44/271811

  Introduction Top

EUS-guided hepaticogastrostomy with transmural stenting EUS-HGS has the following advantages over endoscopic retrograde biliary drainage (ERBD) and percutaneous transhepatic biliary drainage (PTBD).[1],[2] ERBD is not available when the papilla is not accessible endoscopically. However, EUS-HGS is possible even in surgically altered anatomy or inaccessible papilla. One of the major concerns of ERBD is procedure-related acute pancreatitis. In EUS-HGS, traumatic papillary irritation which can develop acute pancreatitis may be avoided. The stent patency might be longer in EUS-HGS than in ERBD since the stents are not needed to be placed across the stricture site. EUS-HGS shows similar efficacy compared to PTBD when performed by expertise, and may be more comfortable and physiologic to the patients than PTBD because of internal drainage. The overall number of reinterventions seems to be lower after EUS-HGS than after PTBD.[1],[3] However, EUS-HGS is still limited because of the complexity of this procedure and the lack of dedicated device for EUS-HGS. Because of the anatomical proximity to the mediastinum, very serious adverse events can occur in EUS-HGS.

  Efficacy of EUS-Guided Hepaticogastrostomy Top

Based on 27 clinical studies, the technical and clinical success rates of EUS-HGS were reported to be 96% (range, 65%–100%) and 90% (range, 66%–100%), respectively [Table 1]. The success rate of EUS-HGS was comparable to ERBD and PTBD procedures.[1],[2] The technical and clinical success rates of EUS-guided choledochoduodenostomy (EUS-CDS) were similar to EUS-HGS; however, EUS-CDS has been more widely used because the extrahepatic biliary access through EUS is closer and easier. Nevertheless, EUS-HGS may be preferred over EUS-CDS as an alternative to ERBD, given the clinical situation where ERBD is not feasible. In cases of surgically altered anatomy or duodenal obstruction, EUS-HGS will be the primary choice.
Table 1: Studies about EUS-HGS

Click here to view

Theoretically, because EUS-HGS stents are placed away from the malignant stricture, the stent patency seems to be longer in EUS-HGS than in ERBD. However, stent patency of EUS-HGS was reported variously, ranging from 62 days to 402 days [Table 1]. Although EUS-HGS may have fewer chance of tumor ingrowth or overgrowth, it can have more cases of stent migration and clogging by food material, and these reasons may shorten the stent patency of EUS-HGS. The location and degree of biliary stricture, presence of gastric or duodenal obstruction, ileus, type and length of the placed stent, and the presence of liver metastasis may affect the stent patency of EUS-HGS. There has been only one prospective study comparing the stent patency between EUS-guided biliary drainage (EUS-HGS and EUS-CDS) and ERBD,[2] and the stent patency was significantly longer in EUS-guided biliary drainage than in ERBD (6-month stent patency 85% vs. 49%, P = 0.001). Ogura et al. reported that EUS-HGS had significantly longer stent patency than EUS-CDS in patients with duodenal obstruction (median 133 vs. 37 days; hazard ratio 0.391, 95% confidence interval 0.156–0.981, P = 0.045), and duodenobiliary reflux caused by duodenal obstruction may contribute shorter stent patency of EUS-CDS.[21] However, in the recent study of our group, there was no significant difference in stent patency between EUS-HGS and EUS-CDS in subgroup analysis of patients with duodenal invasion.[2] EUS-CDS can be performed in patients with type II or III duodenal obstruction (intact duodenal bulb). Further prospective studies comparing EUS-HGS and EUS-CDS among patients with type II or III duodenal obstruction would be warranted.

  Safety of EUS-Guided Hepaticogastrostomy Top

As many clinical data related to EUS-HGS have been reported, this procedure seems to be a safe procedure, and produces fewer procedure-related adverse events than PTBD.[1],[32] The overall rate of adverse events was 18% [range, 0%–50%, [Table 1]. Common adverse events of EUS-HGS include abdominal pain, self-limiting pneumoperitoneum, bile leak, cholangitis, and bleeding. In rare cases, serious adverse events such as perforation, intraperitoneal migration of the stent, and mediastinitis may happen. Even there have been six deaths associated with EUS-HGS, three of which were associated with bile leak, and the remaining three associated with sepsis.[3],[18] EUS-HGS has more types of adverse events than EUS-CDS, and some of them are life-threatening.[15],[33] For beginners, more adverse events occur in EUS-HGS than in EUS-CDS.[12] Therefore, EUS-HGS should be tried after sufficient experience of EUS-guided tissue acquisition, pseudocyst drainage, and EUS-CDS. The learning curve of EUS-HGS is still unclear; however, a recent study revealed that over 33 cases might be required to reach the plateau phase for successful EUS-HGS [Figure 1].[28]
Figure 1: Proposed algorithm for EUS-HGS. *When patient have insufficient intrahepatic ductal dilatation and indwelling percutaneous transhepatic biliary drainage catheter, the conversion of percutaneous transhepatic biliary drainage to EUS-guided hepaticogastrostomy may be considered after failed internalization of percutaneous transhepatic biliary drainage

Click here to view

In order to prevent procedure-related adverse events in EUS-HGS, it is important to reduce the number of accessory changes and shorten the procedure time. For this purpose, a dedicated device for one-step EUS-BD without additional fistula dilation has been introduced, which may result in shortened procedural time with less procedure-related adverse events.[19]

  Limitations of EUS-Guided Hepaticogastrostomy Top

Because EUS-HGS is still technically challenging, it is available only in a small number of hospitals so far. There remains a risk of losing access since only a short length of the guide wire left coiled inside the intrahepatic during the exchange of accessories.[34] For a beginner of EUS-HGS, conversion of PTBD to EUS-HGS would provide an additional advantage to achieve the plateau of learning curve for EUS-HGS.[23] By opacification of the intrahepatic through a PTBD catheter, the practitioner more easily finds the optimal puncture site of the intrahepatic. Even if EUS-HGS fails, the risk of adverse events such as cholangitis or bile leak may decrease because of the indwelling catheter.

In advanced hilar stricture or isolated right intrahepatic bile duct obstruction, EUS-HGS has some technical limitations draining the right intrahepatic. However, several techniques of EUS-HGS have been introduced to drain right lobe as follows: (1) Bridging method that inserts uncovered metal stent between right and left intrahepatic first, then inserts the covered metal stent between left intrahepatic and stomach[35] and (2) hepaticoduodenostomy that access right intrahepatic in the duodenum.[36] However, right-sided biliary access may be difficult because of the acute angulation of the access route.

The long distance of the track through the liver parenchyma between the puncture site in the gastric wall and the intrahepatic contributes procedure-related adverse events.[37] The fistula dilation is also a difficult step, and the use of noncoaxial electrocautery during fistula dilation is a risk factor for procedure-related adverse events.[10],[20] Another big problem is that the stent could migrate into the peritoneal cavity since there is a free space between the liver and the stomach. The movement of the liver during respiration may also lead to stent migration.[20] To prevent stent migration, the distance between the liver and stomach should be as close as possible, and intrachannel stent release technique should be applied while the HGS stent is deployed.[15],[38] Moreover, to prevent stent migration by shortening of the stent, a long stent of 10 cm or more and over 3 cm gastric end of the stent are recommended.[22] In order for EUS-HGS to become more popular, the development of dedicated accessories and devices, and standardization of EUS-HGS technique is mandatory.

  Conclusions Top

EUS-HGS is a very attractive procedure because it can be performed by the same practitioners of ERCP, and it is possible for endoscopically inaccessible papilla. The clinical studies about EUS-HGS after failed ERCP have shown comparative efficacy with fewer adverse events compared to PTBD. However, since most of the procedures in these studies have been done by experts, EUS-HGS should be performed after sufficient practice and experiences of EUS and ERCP, and surgeons and interventional radiologist should also be available to help with the procedure-related adverse events.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lee TH, Choi JH, Park do H, et al. Similar efficacies of endoscopic ultrasound-guided transmural and percutaneous drainage for malignant distal biliary obstruction. Clin Gastroenterol Hepatol 2016;14:1011-9.e3.  Back to cited text no. 1
Paik WH, Lee TH, Park DH, et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: A multicenter randomized clinical trial. Am J Gastroenterol 2018;113:987-97.  Back to cited text no. 2
Sportes A, Camus M, Greget M, et al. Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: A retrospective expertise-based study from two centers. Therap Adv Gastroenterol 2017;10:483-93.  Back to cited text no. 3
Burmester E, Niehaus J, Leineweber T, et al. EUS-cholangio-drainage of the bile duct: Report of 4 cases. Gastrointest Endosc 2003;57:246-51.  Back to cited text no. 4
Kahaleh M, Hernandez AJ, Tokar J, et al. Interventional EUS-guided cholangiography: Evaluation of a technique in evolution. Gastrointest Endosc 2006;64:52-9.  Back to cited text no. 5
Will U, Thieme A, Fueldner F, et al. Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage. Endoscopy 2007;39:292-5.  Back to cited text no. 6
Bories E, Pesenti C, Caillol F, et al. Transgastric endoscopic ultrasonography-guided biliary drainage: Results of a pilot study. Endoscopy 2007;39:287-91.  Back to cited text no. 7
Artifon EL, Chaves DM, Ishioka S, et al. Echoguided hepatico-gastrostomy: A case report. Clinics (Sao Paulo) 2007;62:799-802.  Back to cited text no. 8
Ramírez-Luna MA, Téllez-Ávila FI, Giovannini M, et al. Endoscopic ultrasound-guided biliodigestive drainage is a good alternative in patients with unresectable cancer. Endoscopy 2011;43:826-30.  Back to cited text no. 9
Park DH, Jang JW, Lee SS, et al. EUS-guided biliary drainage with transluminal stenting after failed ERCP: Predictors of adverse events and long-term results. Gastrointest Endosc 2011;74:1276-84.  Back to cited text no. 10
Kim TH, Kim SH, Oh HJ, et al. Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction. World J Gastroenterol 2012;18:2526-32.  Back to cited text no. 11
Vila JJ, Pérez-Miranda M, Vazquez-Sequeiros E, et al. Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: A Spanish national survey. Gastrointest Endosc 2012;76:1133-41.  Back to cited text no. 12
Park DH, Jeong SU, Lee BU, et al. Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video). Gastrointest Endosc 2013;78:91-101.  Back to cited text no. 13
Kawakubo K, Isayama H, Kato H, et al. Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 2014;21:328-34.  Back to cited text no. 14
Paik WH, Park DH, Choi JH, et al. Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy. World J Gastroenterol 2014;20:5051-9.  Back to cited text no. 15
Artifon EL, Marson FP, Gaidhane M, et al. Hepaticogastrostomy or choledochoduodenostomy for distal malignant biliary obstruction after failed ERCP: Is there any difference? Gastrointest Endosc 2015;81:950-9.  Back to cited text no. 16
Umeda J, Itoi T, Tsuchiya T, et al. Anewly designed plastic stent for EUS-guided hepaticogastrostomy: A prospective preliminary feasibility study (with videos). Gastrointest Endosc 2015;82:390-6.e2.  Back to cited text no. 17
Poincloux L, Rouquette O, Buc E, et al. Endoscopic ultrasound-guided biliary drainage after failed ERCP: Cumulative experience of 101 procedures at a single center. Endoscopy 2015;47:794-801.  Back to cited text no. 18
Park DH, Lee TH, Paik WH, et al. Feasibility and safety of a novel dedicated device for one-step EUS-guided biliary drainage: A randomized trial. J Gastroenterol Hepatol 2015;30:1461-6.  Back to cited text no. 19
Khashab MA, Messallam AA, Penas I, et al. International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches. Endosc Int Open 2016;4:E175-81.  Back to cited text no. 20
Ogura T, Chiba Y, Masuda D, et al. Comparison of the clinical impact of endoscopic ultrasound-guided choledochoduodenostomy and hepaticogastrostomy for bile duct obstruction with duodenal obstruction. Endoscopy 2016;48:156-63.  Back to cited text no. 21
Nakai Y, Isayama H, Yamamoto N, et al. Safety and effectiveness of a long, partially covered metal stent for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction. Endoscopy 2016;48:1125-8.  Back to cited text no. 22
Paik WH, Lee NK, Nakai Y, et al. Conversion of external percutaneous transhepatic biliary drainage to endoscopic ultrasound-guided hepaticogastrostomy after failed standard internal stenting for malignant biliary obstruction. Endoscopy 2017;49:544-8.  Back to cited text no. 23
Minaga K, Takenaka M, Kitano M, et al. Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention. Surg Endosc 2017;31:4764-72.  Back to cited text no. 24
Cho DH, Lee SS, Oh D, et al. Long-term outcomes of a newly developed hybrid metal stent for EUS-guided biliary drainage (with videos). Gastrointest Endosc 2017;85:1067-75.  Back to cited text no. 25
Amano M, Ogura T, Onda S, et al. Prospective clinical study of endoscopic ultrasound-guided biliary drainage using novel balloon catheter (with video). J Gastroenterol Hepatol 2017;32:716-20.  Back to cited text no. 26
Moryoussef F, Sportes A, Leblanc S, et al. Is EUS-guided drainage a suitable alternative technique in case of proximal biliary obstruction? Therap Adv Gastroenterol 2017;10:537-44.  Back to cited text no. 27
Oh D, Park DH, Song TJ, et al. Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting. Therap Adv Gastroenterol 2017;10:42-53.  Back to cited text no. 28
Honjo M, Itoi T, Tsuchiya T, et al. Safety and efficacy of ultra-tapered mechanical dilator for EUS-guided hepaticogastrostomy and pancreatic duct drainage compared with electrocautery dilator (with video). Endosc Ultrasound 2018;7:376-82.  Back to cited text no. 29
Okuno N, Hara K, Mizuno N, et al. Efficacy of the 6-mm fully covered self-expandable metal stent during endoscopic ultrasound-guided hepaticogastrostomy as a primary biliary drainage for the cases estimated difficult endoscopic retrograde cholangiopancreatography: A prospective clinical study. J Gastroenterol Hepatol 2018;33:1413-21.  Back to cited text no. 30
Miyano A, Ogura T, Yamamoto K, et al. Clinical impact of the intra-scope channel stent release technique in preventing stent migration during EUS-guided hepaticogastrostomy. J Gastrointest Surg 2018;22:1312-8.  Back to cited text no. 31
Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: A systematic review and meta-analysis. Gastrointest Endosc 2017;85:904-14.  Back to cited text no. 32
Ogura T, Higuchi K. Technical tips for endoscopic ultrasound-guided hepaticogastrostomy. World J Gastroenterol 2016;22:3945-51.  Back to cited text no. 33
Savides TJ, Varadarajulu S, Palazzo L; EUS 2008 Working Group. EUS 2008 working group document: Evaluation of EUS-guided hepaticogastrostomy. Gastrointest Endosc 2009;69:S3-7.  Back to cited text no. 34
Ogura T, Sano T, Onda S, et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: Novel technical tips. Endoscopy 2015;47:72-5.  Back to cited text no. 35
Park DH. Endoscopic ultrasound-guided biliary drainage of hilar biliary obstruction. J Hepatobiliary Pancreat Sci 2015;22:664-8.  Back to cited text no. 36
Boulay BR, Lo SK. Endoscopic ultrasound-guided biliary drainage. Gastrointest Endosc Clin N Am 2018;28:171-85.  Back to cited text no. 37
Anderloni A, Attili F, Carrara S, et al. Intra-channel stent release technique for fluoroless endoscopic ultrasound-guided lumen-apposing metal stent placement: Changing the paradigm. Endosc Int Open 2017;5:E25-9.  Back to cited text no. 38


  [Figure 1]

  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
   Efficacy of EUS-...
   Safety of EUS-Gu...
   Limitations of E...
   Article Figures
   Article Tables

 Article Access Statistics
    PDF Downloaded122    
    Comments [Add]    

Recommend this journal