E-ASSIST: EUS-guided antegrade stent in stent for malignant hilar obstruction—a new management paradigm (with video)

An 83-year-old man with bilateral below-knee amputation presented with ascites and jaundice with a total bilirubin of 10 mg/dL. Computed tomography imaging revealed multicentric hepatocellular carcinoma, with the largest measuring 10 cm × 9 cm × 8 cm involving segments IVA and VIII causing bilateral intrahepatic duct (IHD) dilatation. Endoscopic retrograde cholangiopancreatography failed to cannulate the papilla. Patient refused a percutaneous transhepatic biliary drainage procedure; hence, EUS-guided antegrade biliary drainage was performed. A 19-gauge needle was used to access segment 3 (B3) via the trangastric approach. Cholangiogram showed left intrahepatic stricture. A 0.035-inch guidewire was advanced into the left IHD and across the stricture [Figure 1]. Stricture was dilated with a 6F cystotome and a 4-mm Hurricane balloon catheter. A 6-cm uncovered metal stent (Niti-S LCD biliary stent) was deployed across the stricture [Figure 2] with the proximal flange in the left IHD and the distal flange in the common bile duct with good contrast flow into the duodenum. Transduodenal D1 puncture using a 19-gauge needle into the right intrahepatic bile duct at segment 6 was performed, and contrast injection demonstrated a right IHD stricture [Figure 3]. A 0.035-inch guidewire was advanced into the right IHD, and dilatation of the stricture was performed via 8F cystotome and a 4-mm Hurricane balloon catheter (Boston Scientific Japan, Tokyo, Japan). A second 6-cm uncovered biliary metal stent (Niti-S LCD biliary stent) was then deployed within the previous metal stent in a Y configuration [Figure 4]. Good contrast flow after stent-in-stent deployment was demonstrated. We demonstrate that EUS-guided antegrade stenting with a stent-in-stent deployment technique for drainage of bilateral biliary systems is feasible and effective in patients with malignant hilar (Bismuth IV) obstruction (Video 1). Further prospective studies are warranted to evaluate the safety and efficacy of this novel approach.Figure 1: Left IHD stricture.Figure 2: Left IHD stent via transgastric route.Figure 3: Right IHD stricture.Figure 4: Bilateral stent in stent in Y configuration. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Supplementary Video","caption":"Videos are available only at the official website of the journal (www.eusjournal.com).","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_j7y0huks"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}