Endoscopic ultrasound-guided drainage of bilomas in difficult-to-puncture locations using a sheath-assisted puncture technique

Endoscopic ultrasound-guided drainage of bilomas in difficult-to-puncture locations using a sheath-assisted puncture techniqueBiloma is a complication of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) [1].Despite being the first-line treatment for infected bilomas, percutaneous drainage can affect daily life and pose self-extraction risks, particularly in older patients [2].Endoscopic ultrasound (EUS)-guided drainage offers a viable alternative for internal biliary drainage; however, it can be challenging for the right liver lobe because of its long distance from the gastrointestinal (GI) tract [3][4][5].Here, we describe successful EUS-guided drainage of an infected biloma distant from the GI tract using a sheath-assisted puncture technique ( Fig. 1, Video 1).An 85-year-old man who developed an infected biloma in the posterior liver segment after TACE for HCC ( Fig. 2 a) opted for endoscopic transpapillary drainage because of advanced age and high risk of self-extraction.However, uncontrollable infections necessitated EUS-guided transduodenal drainage with a nasal drainage tube.Biloma recurrence in segment 7 induced an initial reinter-Video 1 Sheath-assisted puncture technique allows the needle tip to reach deeper puncture targets by pushing the sheath of a 19G needle. Fig. 1 Sheath-assisted puncture technique allows the needle tip to reach deeper puncture targets by pushing the sheath of a 19G needle.The 2.6-mm sheath prevented damage to the gastric mucosa and liver parenchyma. Fig. 2 a Computed tomography (CT) revealing the biloma in segment 7 (S7) after trans- catheter arterial chemoembolization for hepatocellular carcinoma.b Endoscopic ultrasound drainage of the S7 was performed, but the infection was uncontrollable (arrow).c Postoperative CT showing that the biloma had shrunk and infection was well controlled (arrow).d X-ray confirming that the nasal drainage tube was well positioned.