Hepaticogastrostomy guided by real-time contrast-enhanced harmonic endoscopic ultrasonography: a novel technique.

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) has recently been developed as an alternative biliary drainage technique for failed endoscopic retrograde cholangiopancreatography (ERCP) [1–3]. A recent review revealed its overall technical success rate to be82% [4], but puncturing the left intrahepatic bile duct (LIBD) is occasionally challenging. Here we present a case in which EUS-HGS was successfully performed under real-time contrast-enhanced harmonic EUS guidance. A 55-year-old woman with obstructive jaundice secondary to gastric cancer was referred to our hospital. She had previously undergone endoscopic transpapillary metal stenting for biliary obstruction caused by lymph node metastasis. Stent occlusion occurred 6 months after stent deployment and an ERCP was attempted; however, the ampulla was inaccessible because of a duodenal stricture. As computed tomography (CT) scanning revealed a dilated LIBD (●" Fig.1), EUSHGS was performed. Although the left hepatic lobe could be visualized well with an echoendoscope from the stomach, the LIBD was invisible. The contrast between the bile duct and the hepatic parenchyma was enhanced by performing contrast-enhanced harmonic EUS. Immediately after an intravenous infusion of sonographic contrast agent (Sonazoid; Daiichi-Sankyo, Tokyo, Japan) had been administered, the dilated LIBD could be identified (●" Fig.2) and was punctured with a 19-gauge aspiration needle (●" Fig.3). After the fistula had been dilated, a covered metal stent was successfully deployed (●" Video1). The strong contrast between the liver parFig.3 Hepaticogastrostomy guided by real-time contrast-enhanced harmonic endoscopic ultrasonography (EUS). The dilated intrahepatic bile duct has been punctured using a 19-gauge aspiration needle and, after aspiration of bile, a small amount of contrast medium has been injected. Fig.2 Contrastenhanced harmonic endoscopic ultrasonography (EUS) image in the post-vascular phase showing the intrahepatic bile duct as a contrast defect. Fig.1 Contrastenhanced computed tomography (CT) image showing a dilated left intrahepatic bile duct. Video 1