Biliary Stenting for Unresectable Malignant Biliary Obstruction
Endoscopic ultrasonography-guidedcholecystogastrostomy using a lumen-apposing metal stentas an alternative to extrahepatic bile duct drainage inpancreatic cancer with duodenal invasion
1Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan; and 2InterventionalEndoscopy Services, California Pacific Medical Center, San Francisco, California, USA
Various approaches to biliary drainage, especially endoscopicultrasonography (EUS)-guided drainage, have become commonlyused as an alternative method for biliary decompression formalignant biliary obstruction. Occasionally, however, duodenalobstruction and non-dilated intrahepatic bile duct impede con-ventional EUS-guided biliary drainage. Herein, we describe acase of cholecystogastrostomy successfully carried out using anewly developed fully covered lumen-apposing self-expandablemetallic stent (SEMS). EUS-guided cholecystogastrostomy shouldbe considered an option for biliary decompression. This is a
particularly ideal alternative if the patient has duodenal strictureswith or without a duodenal metal stent and a non-dilated intra-hepatic bile duct, which suggests the impossibility of choledoch-oduodenostomy and hepaticogastrostomy. Furthermore, thenewly developed fully covered lumen-apposing SEMS seemsideal for EUS-guided cholecystoenterostomy.
CURVED LINEAR-ARRAY ECHOENDOSCOPES arevery useful not only as diagnostic tools for endoscopic
ultrasonography-guided fine-needle aspiration (EUS-FNA)but also as therapeutic strategy-deciding instruments. Interms of therapeutic EUS, recently, EUS-guided drainage(e.g. pancreatic pseudocyst drainage,1 biliary drainage,2 andgallbladder drainage3,4) has been widely carried out by expe-rienced endoscopists. Among these EUS-guided drainageprocedures, biliary drainage has frequently been used as analternative method of biliary decompression for malignantbiliary obstruction. EUS-guided extrahepatic bile duct drain-age and EUS-guided intrahepatic bile duct drainage, asrepresented by choledochoduodenostomy and EUS-guided
hepaticogastrostomy, respectively, are commonly used.However, at times, duodenal obstruction and a non-dilatedintrahepatic bile duct hinder the performance of conven-tional EUS-guided biliary drainage. Herein, we describe acase of cholecystogastrostomy successfully carried out usinga newly developed fully covered lumen-apposing self-expandable metallic stent (SEMS).5
CASE REPORT
A 57-YEAR-OLD MAN with cancer of the head of thepancreas and with a pancreatic pseudocyst as a result of
disruption of the pancreatic duct presented with obstructivejaundice. Direct bilirubin was 9.4 mg/dL and he had highfever and vomiting as a result of distal biliary obstructionand duodenal obstruction caused by cancer invasion in thefirst and second portions of the duodenum. As the duodeno-scope could not reach the papilla, we planned simultaneousdouble stenting using a duodenal stent from the pylorus ringto the second portion of the duodenum and a biliary metalstent for hepaticogastrostomy. Preprocedural magnetic reso-nance cholangiopancreatography showed a mildly dilatedand distorted left intrahepatic bile duct, suggesting thatlarge-bore metal stent placement was not appropriate and
Corresponding: Takao Itoi, Department of Gastroenterology andHepatology, Tokyo Medical University, 6-7-1 Nishishinjuku,Shinjuku-ku, Tokyo 160-0023, Japan. Email: [email protected]†AXIOS stents used in the present study were provided free of chargeby Xlumena Inc. (Mountain View, CA, USA). Takao Itoi holds consult-ant and advisory board positions with Xlumena Inc., and KennethBinmoeller is Chief Medical Officer for, and a stockholder in, XlumenaInc.Received 28 November 2012; accepted 6 February 2013.
that stent patency would be inadequate due to possiblekinking of the edge of the stent within the bile duct. Thus,before the duodenal stenting, EUS-guided cholangiographywas done using a 22-gauge needle (Fig. 1). The puncture wasconducted through the B3 intrahepatic bile duct because of anon-dilated B2 intrahepatic bile duct and possible transe-sophageal puncture. In addition, angulation of the needle tothe intrahepatic bile duct seemed too acute to place the metalstent safely. Interestingly, EUS-guided cholangiography
showed that the gallbladder communicated well with theextrahepatic bile duct. Therefore, EUS-guided gallbladderdrainage was considered an option for biliary decompressionif the duodenal stent did not interfere with the gallbladderstent. We obtained informed consent for EUS-guided gall-bladder drainage after discussing the risks, benefits, andalternatives with the patient and his family.
First, a duodenal metal stent (WallFlex®; Boston ScientificJapan, Tokyo, Japan) was placed across the pyloric ring(Fig. 2). Fortunately, as EUS transgastrically depicted thegallbladder as having no interference from the prior duodenalstent (Fig. 3a), EUS-guided cholecystogastrostomy wascarried out using a lumen-apposing metal stent (AXIOS stent;Xlumena Inc., Mountain View, CA, USA), which is a fullycovered, 10-mm diameter, 10-mm long, nitinol, braided stentwith bilateral 20-mm diameter anchor flanges (Fig. 4).Briefly, a 19-gauge needle (EchoTip; Cook Endoscopy,Winston-Salem, NC, USA) was inserted transgastrically intothe extrahepatic bile duct under EUS visualization (Fig. 3b).6
After the stylet was removed, bile was aspirated and contrastmedium was injected into the gallbladder. A 450-cm long,0.025-inch guidewire (VisiGlide®; Olympus MedicalSystems, Tokyo, Japan) was inserted into the outer sheath(Fig. 5). Following this, the insertion of a bougie by standardendoscopic retrograde cholangiopancreatography (ERCP)injection catheter (ERCP catheter; MTW Endoscopie, Düs-seldorf, Germany), a 4-mm diameter dilating balloon (Hurri-cane; Boston Scientific Japan) was used to dilate the tract.Finally, cholecystogastrostomy was carried out using anAXIOS stent without any adverse events (Fig. 6). The patientrecovered well and laboratory data the following day showedimprovement of liver function. At present, 1 year later,the AXIOS stent in the gallbladder is still patent with nosymptoms.
Figure 1 Endoscopic ultrasonography-guided cholangiographyusing a 22-gauge needle. Cystic duct clearly communicates withthe bile duct.
a b
Figure 2 Duodenal metal stent wasplaced from the pylorus ring to thesecond portion of the duodenum. (a)X-ray image. (b) Endoscopic image.
138 T. Itoi et al. Digestive Endoscopy 2013; 25 (Suppl. 2): 137–141
CURRENTLY, EUS-GUIDED BILIARY drainage is anoption for biliary decompression. In general, EUS-
guided biliary drainage is divided into EUS-guided choledo-choduodenostomy for extrahepatic bile duct drainage, andEUS-guided hepaticogastrostomy for intrahepatic bile duct
drainage. In the present case, EUS-guided hepaticogastros-tomy seemed a standard technique of EUS-guided biliarydrainage. However, current angulation of the needle to theintrahepatic bile duct seemed too acute to place the metal stentsafely. Based on our experience, inappropriate metal stentplacement for EUS-guided hepaticogastrostomy causesstent migration and dysfunction, leading to unnecessary
a b
Figure 3 Transgastric echoendoscopic images. (a) Endoscopic ultrasonography depicts the gallbladder. (b) A 19-gauge needle wasadvanced into the gallbladder.
Figure 4 AXIOS stent (Xlumena Inc., Mountain View, CA, USA) isa fully covered, 10-mm diameter, 10-mm long, nitinol, braidedstent with bilateral 20-mm diameter anchor flanges.
Figure 5 A 0.025-inch guidewire was looped in the gallbladder.
complications. In addition, EUS-guided cholangiographyshowed that the gallbladder communicated well with theextrahepatic bile duct. Thus, we selected EUS-guided chole-cystogastrostomy instead of EUS-guided hepaticogastros-tomy. Fortunately, we demonstrated that gallbladder drainageincluding cholecystogastrostomy and cholecystoduodenos-tomy can serve as an alternative procedure for bile ductdrainage if the cystic duct takes off above the strictures, andthe bile duct and gallbladder communicate well with eachother. If, in fact, it is difficult to puncture the non-dilatedintrahepatic bile duct in the percutaneous transhepatic biliarydrainage procedures in patients with distal biliary strictures orbile duct stones, percutaneous transhepaticgallbladder drainage is conducted instead of bile ductdrainage. Until now, surprisingly, no obvious stent occlusionhas occurred. These results suggest that EUS-guided cho-lecystoenterostomy may be an option for bile duct dra-inage, particularly when double stenting for EUS-guidedcholedochoduodenostomy and hepaticogastrostomy are dif-ficult or impossible.
Because the gallbladder and stomach or duodenum do notadhere to each other, drainage of the gallbladder carries arisk of leakage of bile or enteric contents within the gallblad-der. In the present case, we did not observe leakage afterdeployment of the stent and we attribute this to the lumen-to-lumen apposition provided by the flanges as well as thefull-silicone covering. Previously, because we have encoun-tered bile leakage during EUS-guided cholecystoenteros-tomy using a double pig-tail plastic stent,3 we advocated that,among endoscopic approaches, further research was neededregarding the EUS-guided approach to the gallbladder,including the indication and standardization of the proce-dure. We now believe that this procedure cannot be safely
recommended. However, dedicated devices such as theAXIOS stent allow safe and reliable therapeutic EUS.4,7
EUS-guided cholecystogastrostomy for decompression ofthe bile duct is suitable in the following situations: (i) distalbiliary obstruction; (ii) the cystic duct takes off above thestrictures and the bile duct and gallbladder communicatewell with each other; (iii) duodenal obstruction that requiresa duodenal stent; and (iv) inappropriate EUS-guided hepat-icogastrostomy as a result of a non-dilated intrahepatic bileduct and/or acute angulation of needle puncture for the metalstent placement.
In conclusion, EUS-guided cholecystogastrostomy shouldbe considered as an option for biliary decompression. Inparticular, when a patient has a duodenal stricture, with orwithout a duodenal metal stent, and a non-dilated intrahe-patic bile duct suggesting choledochoduodenostomy andhepaticogastrostomy are not possible, it may be an idealalternative. Furthermore, the newly developed fully coveredlumen-apposing metal stent would appear to be ideal forEUS-guided cholecystoenterostomy.
ACKNOWLEDGMENTS
WE ARE INDEBTED to Professor James M. Varda-man, Associate Professor Edward Barroga, and Pro-
fessor J. Patrick Barron, Chairman of the Department ofInternational Medical Communications at Tokyo MedicalUniversity for their editorial review of the manuscript.
CONFLICT OF INTERESTS
THE AXIOS STENTS were provided free of charge byXlumena Inc. (Mountain View, CA, USA). Takao Itoi
holds consultant and advisory board positions with Xlumena
Inc., and Kenneth Binmoeller is Chief Medical Officer for,and a stockholder in, Xlumena Inc. Fumihide Itokawa, JunkoUmeda, and Reina Tanaka declare no conflict of interests forthis article.
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