Holmium: YAG laser lithotripsy through an EUS-guided hepaticogastrostomy route

Holmium: YAG laser lithotripsy through an EUS-guided hepaticogastrostomy route

VideoGIE forward while the endoscope is simultaneously withdrawn in an exchange maneuver (Fig. 1; Video 1, available online at www.giejournal.org). I...

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VideoGIE

forward while the endoscope is simultaneously withdrawn in an exchange maneuver (Fig. 1; Video 1, available online at www.giejournal.org). In this patient, the stent was removed 2 months later, and an upper GI examination showed no further leak. Our novel OTSS method creates and places a custom-length stent longer than is commercially available. Because it rests against the prepyloric antrum, migration is rarely an issue. At first glance it appears to be costly, but the OTSS actually reduces expenses and patient discomfort by minimizing repeated procedures and replacement of stents.

DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Sami Almaskeen, MD, Simon K. Lo, MD, Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA http://dx.doi.org/10.1016/j.gie.2015.10.017

Holmium: YAG laser lithotripsy through an EUS-guided hepaticogastrostomy route

Figure 1. A, After EUS-guided hepaticogastrostomy by using a fully covered metal stent (FCSEMS), the impacted stone moved into the FCSEMS. B, Holmium: YAG laser lithotripsy through the FCSEMS under peroral video cholangioscopic visualization.

This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.

cholangitis without the recurrence of cancer. CT showed a dilated intrahepatic bile duct (IHBD) with biliary stones. First, BE-guided endoscopic retrograde cholangiography, dilation of the anastomosis by using a balloon dilator, and removal of the stones were performed. However, 1 impacted stone behind the left IHBD stricture due to repeated cholangitis remained. Next, EUS-HGS was performed by using a fully covered self-expandable metal stent (FCSEMS) (WallFlex, 8 mm in diameter, 6 cm in length; Boston Scientific, Tokyo, Japan). One week later, YAG-LL through the FCSEMS under per-oral video cholangioscopic visualization (CHF-B260; Olympus Medical Systems, Tokyo, Japan) was performed, and the stone was removed completely (Fig. 1, Video 1, available online at www.giejournal.org). The patient’s symptoms rapidly disappeared. CT on the following day showed disappearance of the stones. One month later, the FCSEMS was removed.

830 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 4 : 2016

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Treatment of biliary calculi in patients with a surgically altered anatomy is often challenging despite the development of balloon enteroscopy (BE). To our knowledge, this is the first report of holmium: YAG laser lithotripsy (YAG-LL) via an EUS-guided hepaticogastrostomy (EUSHGS) site for an impacted stone in the intrahepatic bile duct in a patient after pancreaticoduodenectomy (PD). An 80-year-old woman who underwent PD 6 years earlier for cancer of the pancreatic head presented with a high fever and abdominal pain due to repeated occurrences of

VideoGIE

DISCLOSURE Drs Tonozuka and Itoi are on the Speakers’ Bureau of Boston Scientific Japan. All other authors disclosed no financial relationships relevant to this publication.

Ryosuke Tonozuka, MD, Takao Itoi, MD, FASGE, Atsushi Sofuni, MD, Takayoshi Tsuchiya, MD, Kazuhiko Kasuya, MD, Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan http://dx.doi.org/10.1016/j.gie.2015.09.044

Simplified reintervention method of EUS-guided hepaticogastrostomy stent obstruction

Figure 1. A, The covered site of the fully covered self-expandable metallic stent is successfully penetrated with a diathermic dilator. B, The diathermic dilator is inserted into the hepaticogastrostomy (HGS) stent. C, The HGS stent is occluded because of mucosal hyperplasia; the antegrade stent is also occluded by tumor overgrowth.

A 77-year-old woman was admitted to our hospital because of obstructive jaundice. She underwent EUSguided antegrade stenting and hepaticogastrostomy (HGS) stenting with use of an end-bare type fully covered selfexpandable metallic stent (FCSEMS, Niti-S, 10 mm  10 cm, TaeWoong Medical, Seoul, Korea) for obstructive jaundice caused by pancreatic cancer 7 months earlier. Reintervention was attempted. First, an ERCP catheter was inserted into the HGS stent, but it could not be advanced because of the limited push ability resulting from the protruding FCSEMS. Trimming the FCSEMS with argon plasma coagulation (APC) was considered, but this technique might have entailed a relatively long procedure time in addition to being cumbersome. Therefore, the covered site of the FCSEMS (Figs. 1A and 1B) was penetrated by use of a diathermic dilator (Cysto-Gastro-Set; Endo-Flex, GmbH, Voerde, Germany) and an electrosurgical generator

(ICC200, Erbe, Germany; APC mode, 80 W) (Video 1, available online at www.giejournal.org). After this procedure, an ERCP catheter was inserted and was easily advanced into the intestine. Both the EUS antegrade stent and the HGS stent were occluded (Fig. 1C). Stent placement from the occluded antegrade stent to the upper-common bile duct was first performed with the use of an FCSEMS. Stent placement for the occluded HGS stent was also performed by use of an uncovered metallic stent. After this procedure, the obstructive jaundice was completely resolved. This technique is simpler to perform than the trimming technique, and it is a useful method of re-intervention for EUS-HGS stent obstruction.

This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.

Takeshi Ogura, PhD, MD, Daisuke Masuda, PhD, MD, Toshihisa Takeuchi, PhD, MD, Shinya Fukunishi, PhD, MD, Kazuhide Higuchi, PhD, MD, Second Department of Internal Medicine, Osaka Medical College, Osaka, Japan

www.giejournal.org

DISCLOSURE All authors disclosed no financial relationships relevant to this publication.

http://dx.doi.org/10.1016/j.gie.2015.10.008

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