Combined bridging and antegrade stent placement during transmural treatment for malignant hilar biliary obstruction in a patient with surgically altered anatomy

摘要

Recently, bilateral biliary drainage has been considered as the recommended approach for malignant hilar biliary obstruction (MHBO). 1 Patients with surgically altered anatomy (SAA) usually represent a challenge for enteroscopy-assisted ERCP (E-ERCP), with its demanding procedure and dedicated technique. This challenge is greatly increased if SAA is combined with MHBO, espe- cially with the limited availability of suitable metal stents for E-ERCP. EUS-guided hepaticogastrostomy (EUS-HGS) has become a feasible alternative approach for this group of patients, allowing bilateral drainage through the bridging technique using an uncovered self-expandable metal stent (SEMS) across the hilar malignant stricture joining the right and left hepatic ducts (RHDs and LHDs, respectively). 2 Furthermore, combined EUS-HGS with an- tegrade common bile duct (CBD) stent placement was re- ported to prolong stent patency, 3 mostly related to securing the natural antegrade bile flow. Herein, we present a successful transmural combined bridging and antegrade stent placement for MHBO in a patient with SAA (Video 1, available online at www.giejournal.org).