Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy

Figure 1 Balloon dilation catheter and metal stent. A: A 4 mm balloon dilation catheter with stainless steel stiffening stylet to augment pushability (arrow); B: An 8 mm in diameter, dual-flap fully covered metal stent.

Figure 2 Endoscopic ultrasonography-guided hepaticogastrostomy using a 4 mm balloon dilation catheter with stainless steel stylet and an 8 mm fully covered metal stent with dual flaps. A: A 0.035-inch guidewire was introduced into the bile duct and fistula dilation was performed in two sites (liver parenchyma and fistula tract) using a 4 mm biliary balloon dilatation catheter; B: The dual-flap fully covered metal stent was deployed within the bile duct (half of metal stent) under echoendoscopic and fluoroscopic guidance, and echoendoscope channel (remained portion of metal stent) under fluoroscopic guidance, and then placed in hepaticogastrostomy site.

Figure 3 Determination of stent length. The length of an endoscopic ultrasonography needle between gastric wall and punctured left hepatic duct was 4.48 cm (4.48 cm × 2 + 1 cm = 9.96 cm). Based on our formula, a 10 cm fully covered metal stent was placed for this patient.

Figure 4 Development of pseudoaneurysm as a late adverse event after endoscopic ultrasonography-guided hepaticogastrostomy. A: There was huge fresh blood clot attached to stent in endoscopic finding; B and C: Since pseudoaneurysm from left hepatic artery was noted in CT and angiography, hemostasis was achieved by embolization of the feeding vessel from the left hepatic artery (arrow).