Needle-free technique to prevent guidewire damage during endoscopic ultrasound-guided hepaticogastrostomy

Abstract

Figures

Endoscopic ultrasound images. a Guidewire damage occurred (arrow) during insertion. b After the liver impaction technique, guidewire advancement into the hepatic hilar site was performed successfully. c The needle was completely pulled within the sheath (arrow). d After the sheath was pulled back into the echoendoscope, guidewire deployment into the common bile duct was performed successfully.

Metal stent deployment from the intrahepatic bile duct to the stomach was performed successfully.

Full text

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is now widely performed for patients with duodenal obstruction or surgically altered anatomy. During EUS-HGS, guidewire insertion may be a challenging step, as previously reported 1 . To improve the technical success rate of guidewire manipulation without causing guidewire damage by shearing, the liver impaction technique can be helpful 2 3 . However, if the angle between the needle and the bile duct is acute, guidewire damage can occur, even if the liver impaction technique is used. To overcome this, we perform guidewire manipulation using a needle-free technique. Technical tips for the needle-free technique are presented.

An 80-year-old woman was admitted to our hospital for the treatment of obstructive jaundice caused by cancer of the head of the pancreas. After duodenal stent deployment, EUS-HGS was attempted. The intrahepatic bile duct was punctured using a 19-G needle, and contrast medium was injected. On cholangiography, it was seen that the angle between the biliary tract and the needle was acute. The 0.025-inch guidewire was therefore advanced into the periphery of the bile duct, but guidewire damage occurred again ( Fig. 1 a ). To manipulate the guidewire, the liver impaction technique was used, and the guidewire could be directed to the intrahepatic bile duct ( Fig. 1 b ). To advance the guidewire into the common bile duct, the guidewire was pulled back ( Fig. 1 c ), but guidewire shearing occurred again. Therefore, the sheath of the needle was pulled back into the EUS scope ( Fig. 1 d ). By doing so, the angle between the needle and the guidewire increased to 180 degrees, and the guidewire could be manipulated easily. After successful guidewire deployment within the common bile duct, a partially covered, self-expandable, metal stent was deployed without any adverse events ( Fig. 2 , Video 1 ).

Endoscopic ultrasound images. a Guidewire damage occurred (arrow) during insertion. b After the liver impaction technique, guidewire advancement into the hepatic hilar site was performed successfully. c The needle was completely pulled within the sheath (arrow). d After the sheath was pulled back into the echoendoscope, guidewire deployment into the common bile duct was performed successfully.

Metal stent deployment from the intrahepatic bile duct to the stomach was performed successfully.

Guidewire manipulation was performed using the needle-free technique.Video 1

In conclusion, in cases of difficult guidewire manipulation during EUS-HGS, the needle-free technique might be helpful to prevent guidewire damage and improve the technical success of guidewire manipulation.

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