Successful re-intervention with metal stent trimming using argon plasma coagulation after endoscopic ultrasound-guided hepaticogastrostomy.

Recently, endoscopic ultrasound (EUS)guided biliary drainage has been introduced as an alternative method after failed endoscopic biliary drainage, particularly in patients with a pre-existing duodenal obstruction [1–3]. A longer self-expandable metal stent (SEMS) is usually used for EUS-guided hepaticogastrostomy (EUS-HGS) to prevent stent migration. However, re-intervention after EUS-HGS is challenging because of the protrusion of the SEMS into the stomach. Metal stent trimming using argon plasma coagulation (APC) has been reported to be a useful option for stent-related complications such as dislocation [4,5]. We report a case in which successful re-intervention after EUS-HGS was made possible by metal stent trimming using APC. A nonagenarian woman with advanced ampullary cancer was admitted to our center. She had a history of endoscopic transpapillary bile duct stenting and duodenal stenting covering the papilla, followed by EUS-HGS with an 8-mm diameter, 12-cm long, silicone-covered nitinol braided stent, with a 1-cm uncovered portion at the proximal end (Niti-S biliary S-type; Taewoong Medical, Seoul, South Korea). The patient developed recurrent cholangitis caused by sludge formation 3 months after HGS. As she showed a good performance status, we attempted therapeutic endoscopic intervention via the HGS site; however, intervention was difficult beFig.1 Protrusion into the stomach of the long self-expandable metal stent (SEMS) used for endoscopic ultrasoundguided hepaticogastrostomy (EUS-HGS): a on computed tomography (CT) scan; b on endoscopy.