Gastroenterology and Hepatology Unit, Department of Medicine, Faulty of Medicine, University of Malaya;
Gastroenterology and Hepatology Unit, Department of Medicine, Faulty of Medicine, University of Malaya.
J Vis Exp. 2022 Mar 25(181). doi: 10.3791/63146.
Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage. Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 µmol/L (<15) during presentation. A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 µmol/L and 14 µmol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.
患有不可切除的恶性胆道梗阻的患者通常需要胆道引流来减压胆道系统。只要有可能，内镜逆行胰胆管造影（ERCP）就是主要的胆道引流方法。如果 ERCP 失败，则使用经皮经肝胆道引流（PTBD）作为挽救方法。超声内镜引导下胆道引流（EUS-BD）提供了一种可行的替代胆道引流方法，其中一种方法是超声内镜引导下经肝胃吻合术（EUS-HGS）。在这里，我们描述了一种不可切除的恶性肝门胆管梗阻病例中 EUS-HGS 技术，以实现胆道引流。这里介绍的是一位 71 岁女性的病例，她有 2 周无痛性黄疸和体重减轻。计算机断层扫描（CT）成像显示 4 x 5 厘米的肝门肿瘤伴有淋巴结病和肝转移。病变的超声内镜细针活检（FNB）与胆管癌一致。她就诊时的胆红素水平为 212 µmol/L（<15）。使用线性回声内镜定位肝脏的左侧扩张肝内胆管（IHD）。识别并使用 19 G 针穿刺节段 3 扩张的 IHD。在透视引导下使用造影剂使 IHD 显影。使用 0.025 英寸导丝对 IHD 进行插管。随后使用 6 Fr 电切扩张器和 4 毫米胆道球囊扩张器扩张瘘管通道。在透视引导下放置长度为 10 厘米的部分覆盖金属支架。支架的远端在 IHD 中打开，近端在回声内镜的工作通道内释放并进入胃内。患者在手术后三天出院。在第二周和第四周进行的随访显示，胆红素水平分别为 30 µmol/L 和 14 µmol/L。这表明 EUS-HGS 是不可切除的恶性胆道梗阻患者胆道引流的一种安全方法。
