EUS-guided hepaticogastrostomy stent in colangiocarcinoma of the middle port of the common bile duct: case report
Catalina Diaconu1, Vasile Sandru2, Gabriel Constantinescu2, Madalina Ilie2
1Gastroenterology department, Central Military Emergency University Hospital, Bucharest, Romania
2Gastroenterology department, Floreasca Clinical Emergency Hospital, Bucharest, Romania
Introduction
Interventional procedures using endoscopic ultrasound (EUS) have gained power in the world of gastroenterology in the last decade. We can now talk of EUS-guided hepaticogastrostomy as the approach of intrahepatic bile ducts via the gastric wall. This procedure was developed as substitute for biliary drainage. Even though it has a high technical rate of success that varies from 65% to 100%, this method has a 23% overall adverse event rate.
Case-report
56 year-old Caucasian malewith no prior historypresented to the emergency room for jaundice and abdominal pain, that appeared 3 weaks prior to presentation. Biological profile shows leucocitosis with neutrophilia, cholestasis (total bilirubin of 13mg/dL with conjugated bilirubin of 9mg/dL) and pancreatic lipase of 1900U/L. Abdominal ultrasound revealed dilated common bile duct (15mm)and intrahepatic bile ducts, multiple hyperechoic liver nodules with hypoechoic halo (suggestive for liver metastasis), globular cholecyst with biliary sludge and dilated Wirsung duct (7mm). EUS confirmed the ultrasound aspects and completed them by finding a hypoechoic, heterogenous, imprecisely defined mass in the middle-distal part of the common bile duct of 36/30mm with vascular Doppler signal. The presumptive diagnosis was of cholangiocarcinoma with hepatic metastasis. The patient opted for EUS-guided hepaticogastrostomy with the following steps:with a 19Gauge needle the left branch of the bile duct is intercepted, guide wire is inserted followed by metallic tip canula of 5French. Afterwards contrast substance is introduced and the CBP is highlighted with a medial-distal stenosis.The trajectory is dilated with a 6mm balloon on the guide wire and the expandable fully covered metallic stent of 6cm/8mm is inserted with efficient drainage of bile.
Conclusion
Despite the fact that EUS-guided hepaticogastrostomy has few indications, it is an innovative and minimaly invasive technique that offers a better prognosis for many patients.
Keywords:hepaticogastrostomy, endoscopic ultrasound, biliary drainage
Hepaticogastrostomieghidataecoendoscopic in colangiocarcinom al portiuniimedii a caiibiliareprincipale: studiu de caz
Catalina Diaconu1, Vasile Sandru2, Gabriel Constantinescu2, Madalina Ilie2
1Departamentul de gastroenterologie, SpitalulMilitar Central Bucuresti, Romania
2Departamentul de gastroenterologie, Spitalul Clinic de UrgentaBucuresti, Romania
Introducere
Procedurileinterventionaleecoendoscopice au capatatimportanta in lumeagastroenterologiei in ultimuldeceniu.Hepaticogastrostomiaghidataecoendoscopiceste o procedurapentru a drenacailebiliareintrahepaticetransgastric. Aceastaprocedura a fostdezvoltataca o alternativapentrudrenajulbiliar.Desi are rata de success crescuta (intre 65% si 100%), rata reactiilor adverse estecrescuta (25%).
Studiu de caz
Barbatcaucazian in varsta de 56 de ani, faraantecedentepersonalepatologice se prezinta la camera de gardapentruictersidureriabdominalece au aparut cu 3 saptamani anterior prezentarii. Profilul biologic arataleucocitoza cu neutrofilie, colestaza (bilirubinatotala de 13mg/dL cu forma conjugata de 9mg/dL) silipazapancreatica de 1900U/L. Ecografiaabdominalaaaratatcalebiliaraprincipala (CBP) dilatata de 15mm sicailebiliareintrahepaticedilatate, multipliinodulihiperecogenihepatici cu halouhipoecogen, colecistglobulos cu sludge biliarsi duct Wirsungdilatat (7mm). Ecoendoscopia a confirmatdateleecograficesi le-a completatgasind o masahipoecogena, heterogena, imprecisdelimitata, situata in portiuneamijlocie a CBP de 36/30mm cu semnal vascular Doppler prezent. Diagnosticulprezumtiv a fostcolangiocarcinom cu determinarisecundarehepatice.Pacientul a optatpentruhepaticogastrostomiaghidataecoendoscopic cu pasiiurmatori: cu un ac de punctie de 19Gauge se patrunde in ramulstang al caiibiliare commune, se inseraghidmetalic, apoicanula cuvarfmetalic de 5French. Se introducesubstanta de contrast si se evidentiaza CBP dilatat cu stenozamedio-distala. Traiectoriaestedilatata cu balon de 6mm pefirulghid,apoi se introduce stent metalicacoperit de 6cm/8mm cu drenajeficientbiliar.
Concluzie
Desihepaticogastrostomiaghidataecoendoscopic are putineindicatiiearamane o tehnicainovativasi minim invazivaceofera prognostic favorabilpentru multi pacienti.
Cuvintecheie:hepaticogastrostomie, ecoendoscopie, drenajbiliar