# A Possible Contraindication for Endoscopic Ultrasound-Guided Hepaticogastrostomy: A Giant Hiatal Hernia

## TL;DR

A giant hiatal hernia may make a specific endoscopic procedure risky due to organ movement during breathing.

## Contribution

Identifies a potential contraindication for EUS-HGS due to dynamic organ movement caused by a giant hiatal hernia.

## Key findings

- A giant hiatal hernia caused unstable scope positioning during EUS-HGS.
- Stent migration into the abdominal cavity occurred post-procedure.
- Dynamic liver and stomach movement increased air leakage and hindered stable fistula formation.

## Abstract

We present the case of an 82-year-old female with obstructive jaundice secondary to a malignant distal biliary stricture. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed. The presence of a giant hiatal hernia induced dynamic liver movement during respiration, leading to unstable scope positioning. Despite the successful placement of a long, partially covered metal stent from the left intrahepatic bile duct to the intra-abdominal stomach, computed tomography performed three days later revealed free air and an increased distance between the liver and stomach. A subsequent endoscopy confirmed impending stent migration into the abdominal cavity, necessitating the insertion of an additional metal stent through the existing stent's mesh. The presence of a giant hiatal hernia may be considered a relative contraindication for EUS-HGS due to dynamic movements of the stomach and liver during respiration, which can cause stent migration, increased air leakage, and difficulty in establishing a stable fistula between these organs.