<scp>EUS</scp> ‐Guided Hepaticogastrostomy With a Right‐to‐Left Hepatic Duct Bridging Stent for Refractory Mucin Plug Cholangitis Caused by an Intraductal Papillary Mucinous Neoplasm‐Related Pancreatobiliary Fistula

Pancreaticobiliary fistulas associated with intraductal papillary mucinous neoplasm (IPMN) can cause biliary obstruction, and biliary stenting may fail due to stent occlusion or migration. Alternative strategies, including large-diameter fully covered self-expandable metal stents (FCSEMS), EUS-guided hepaticogastrostomy (EUS-HGS), and surgery, have been reported [1-4]. A 91-year-old man with IPMN developed refractory mucin plug cholangitis secondary to a pancreaticobiliary fistula (Figure 1a–c). Initial management with transpapillary plastic stenting and nasobiliary drainage, followed by bilateral half-pigtail plastic stents, resulted in early occlusion (Figure 1d,e). Subsequent pancreatobiliary fistula closure using a 10-mm FCSEMS failed because of early stent migration (Figures 1f and 2a). Surgical intervention was contraindicated because of advanced age and poor performance status. We therefore planned EUS-HGS with right-to-left hepatic duct bridging (EUS-HGSB) using an FCSEMS. After balloon sweeping of the bile duct to remove mucus, a half-pigtail plastic stent was placed in the right posterior duct to prevent obstruction by the bridging FCSEMS (Figure 2b,c). The segment 3 branch was punctured from the stomach under EUS guidance, and guidewires were advanced into the right anterior duct using a double-guidewire technique. An 8-mm FCSEMS (Hanaro Benefit; Boston Scientific, Tokyo, Japan) was deployed to create the bridging stent, followed by placement of an 8-mm partially covered SEMS (Spring Stopper; Taewoong Medical, Seoul, Korea) to complete the EUS-HGS tract (Figure 2d–f), given the prolonged patency reported for SEMS in EUS-HGS [5]. Despite the risk of peripheral bile duct occlusion, we favored FCSEMS bridging to act as an antireflux barrier against mucin inflow into the intrahepatic ducts, thereby reducing cholangitis recurrence. No procedure-related adverse events occurred. Jaundice resolved, and the patient was discharged. No recurrence of cholangitis was observed at the 3-month follow-up. This case suggests that EUS-HGSB using FCSEMS may be an effective option for refractory mucin plug cholangitis caused by IPMN-related biliary fistula (Video 1). K.T. designed the study and drafted the manuscript. S.A. and T.O. supervised this study and critically revised the manuscript for important intellectual content. The authors would like to thank Takumi Sugihara, Kensei Kawasaki, Aoi Koizumi, Sayuri Hashimoto, Kaho Takagi, Yoshihiro Shima, Tomoya Hashimura, Kento Hisamatsu, Shuta Otachi, Kenji Matsuo, Yuki Kano, Eisuke Nakao, and Eisuke Akamine for their kind support for this study. The authors have nothing to report. This study was approved by the Institutional Review Board of Tane General Hospital (approval no. 2024-43). The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.