ENDOSCOPIC ULTRASOUND-GUIDED HEPATICOGASTROSTOMY IN MALIGNANT DUODENAL OBSTRUCTION.

Introduction. Endoscopic retrograde cholangiopancreatography (ERCP) is the main procedure for managing obstructive biliary disease. In the context of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). We report one case of successful biliary decompression through direct transluminal stenting using EUS guidance. Case presentation. We report the case of a 60-year-old female patient with stage IV colorectal adenocarcinoma previously submitted to palliative gastrojejunostomy L-L for duodenal malignant obstruction. The patient presented with obstructive jaundice, cholestasis, and inflammatory syndrome due to local relapse of her malignancy and peritoneal carcinomatosis. The papillary region was not reached by conventional enteroscopy/duodenoscopy. EUS was performed with a linear therapeutic echoendoscope, and intrahepatic biliary duct dilation was confirmed. With the echoendoscope positioned in the upper part of the lesser curvature, a segment III intrahepatic bile duct was punctured with a 19-G needle. A guidewire was then advanced through the needle to the intrahepatic ducts, followed by dilation with a cystotome. A proximally covered metal stent was then delivered into the left hepatic bile duct through the stomach wall, but the length of the remaining part of stent into the stomach was insufficient, so a second partially covered metal biliary stent was placed inside the metal stent. The patient was discharged 6 days after the procedure with regression of biliary retention. The stent was still patent 60 days after the procedure and the patient restarted chemotherapy. Discussion and conclusion. EUS-BD has emerged as an alternative to percutaneous and surgical drainage in cases where ERCP techniques are difficult or not feasible. Conventionally, percutaneous drainage is considered the rescue therapy in the setting of ERCP failure. Although the technical success rate of percutaneous drainage is over 95%, drainage complications continue to be a major problem along with the significantly reduced quality of life. A recent review compared the efficacy and safety of EUS-BD and PTBD, proving equivalent technical success. However, EUS-biliary drainage was associated with better clinical success, fewer post-procedure adverse events, and lower reintervention, with a stent patency of 329 days. No significant differences were observed for the duration of hospital stay between the two procedures, but EUS-biliary procedure was more cost-effective. In conclusion, EUS-BD is a useful tool in case of failure of ERCP or altered anatomy, with a high rate of technical success and clinical efficacy. [ABSTRACT FROM AUTHOR]