Rescue antegrade diathermic dilation of hyperplastic tissue at partially covered metallic stent after EUS-guided hepaticogastrostomy

Endoscopic ultrasonography-guided antegrade stenting (EUS-AGS) and EUSguided hepaticogastrostomy (EUS-HGS) are suitable for obstructive jaundice associated with gastric outlet obstruction or surgically altered anatomy [1]. Recently, a long partially covered self-expandable metallic stent (LPC-SEMS) has been developed to prevent stent migration and bile leakage and allow safe and effective EUS-HGS.However, one disadvantage of the LPC-SEMS is tissue hyperplasia at the uncovered portion of the stent [2]. Here, we present the case of a patient who underwent a rescue procedure using antegrade diathermic dilation for hyperplastic tissue occlusion of an LPC-SEMS and for tumor ingrowth into an uncovered SEMS placed for EUS-AGS. A 60-year-old man with unresectable gastric cancer was admitted with gastric outlet obstruction and obstructive jaundice. He had undergone EUS-AGS using an uncovered metallic stent and EUSHGS using a LPC-SEMS (diameter 6mm, length 120mm, uncovered proximal portion 10mm; Taewoong Medical, Seoul, Korea). He again developed obstructive jaundice 7 months later. Antegrade cholangiography via the LPC-SEMS revealed perihilar bile duct stricture due to hyperplasia at the LPC-SEMS (▶Fig. 1). It was not possible to pass a tapered endoscopic retrograde cholangiopancreatography (ERCP) catheter through the stricture (▶Video1). We successfully dilated the stricture using 6-Fr wire-guided diathermic dilation (Cysto-Gastro-Set; Endo-Flex, Voerde, Germany) (▶Fig. 2, ▶Video1). Antegrade cholangiography showed free drainage through the previously hyperplastic area at the uncovered portion of the stent. No stent was placed as the previously occluded LPCSEMS was now patent (▶Fig. 3). Subsequent antegrade cholangiography revealed occlusion of the uncovered metallic stent due to tumor ingrowth (▶Fig. 4 a). Passage was successfully obtained with antegrade diathermic dilation (▶Fig. 4b). Finally, an ultraslim uncovered SEMS (BileRush Selective, 5.7-Fr, diameter 10mm; Piolax Medical Devices, Kanagawa, Japan) was placed using a stent-in-stent method, without complications (▶Fig. 5, ▶Video1). Recurrent biliary obstruction caused by tissue hyperplasia is an unresolved major problem of the LPC-SEMS, and the optimal rescue technique has not been established. EUS-guided antegrade diathermic dilation has been recently reported [3–5]. To our knowledge, this is the first report of rescue for hyperplastic tissue occlusion of an LPC-SEMS that used wire-guided antegrade diathermic dilation with no need for secondary stenting. This rescue technique is a useful method of recanalization of an LPCSEMS occluded by hyperplastic tissue.