EUS-Guided Hepaticogastrostomy: Technical Tips and Tricks
Pre-Procedural Planning
Pre-procedural MRCP or contrast-enhanced CT is mandatory to understand biliary anatomy, identify the optimal puncture site, and plan the approach. 1, 2 This imaging allows you to select the location with the shortest distance between the gastric wall and intrahepatic bile duct, confirm absence of interposed vasculature, and ensure maximal stability for tract dilation and stent deployment. 1
Patient Selection and Preparation
Administer prophylactic antibiotics covering biliary flora (second-generation cephalosporin or fluoroquinolone) within 60 minutes before the procedure. 1, 3 This prevents cholangitis and septicemia from bacterial translocation during manipulation of the obstructed biliary system. 1
Ensure multidisciplinary support is available, including interventional radiology, surgery, and anesthesiology, as EUS-HGS carries risk of severe adverse events like bile leak, perforation, and bleeding. 1, 2
Technical Execution
Needle Selection and Bile Duct Puncture
Use a 19-gauge FNA needle for intrahepatic bile duct puncture. 1 This allows passage of 0.035 inch or 0.025 inch guidewires, which provide adequate stability for subsequent tract dilation. 1 Flexible nitinol needles may improve maneuverability in angulated positions. 1
Target segment 2 or 3 of the left hepatic duct from the gastric body, as this provides the most favorable angle and shortest distance for transgastric access. 4, 5 Always maintain needle tip visualization under EUS guidance to avoid vascular injury. 2
Guidewire Manipulation
Advance a 0.035 inch or 0.025 inch guidewire with a floppy hydrophilic tip through the needle into the bile duct. 1 These wire sizes provide sufficient stability for tract dilation while reducing risk of kinking when negotiating strictures. 1 A 450 cm wire is commonly used, though some centers use shorter 240 cm wires for faster accessory exchange. 1
Avoid thinner wires (0.018 inch or 0.021 inch) as they kink easily and lack stability for stenting. 1
Tract Dilation
Dilate the hepaticogastric tract using catheters, balloons, or cystotomes—never use a precut papillotome. 1 The size of dilation depends on the stent diameter being deployed. 1
Adequate tract dilation is critical to prevent bile leak and facilitate stent deployment. 4, 5
Stent Selection and Deployment
Use fully or partially covered self-expandable metal stents (SEMS) for transluminal hepaticogastrostomy to prevent bile leak. 1 Covered stents significantly reduce adverse events compared to plastic stents (13% vs 42.8%, P=0.01) and lower cholangitis rates (3% vs 11%, P=0.02). 1
Lumen-apposing metal stents (LAMS) with dumbbell-shaped flanges provide anchoring and may reduce migration risk. 1, 6 Novel designs with spring-like anchoring functions on the gastric side show promise in preventing migration. 6
Deploy the stent under combined EUS and fluoroscopic guidance to ensure proper positioning across the hepaticogastric fistula. 5
Common Pitfalls and How to Avoid Them
Bile Leak Prevention
- Bile leak is the most common adverse event (2.4% incidence), occurring when the fistula is inadequately sealed. 7 Prevent this by ensuring adequate tract dilation before stent deployment and using covered metal stents rather than plastic stents. 1, 4
Stent Migration
- Stent migration into the peritoneal cavity is a catastrophic complication. 4, 6 Minimize risk by selecting stents with anti-migration features (flanges or spring stoppers) and ensuring proper deployment with both ends well-apposed to tissue. 6
Bleeding and Vascular Injury
- Always visualize the needle tip during puncture and avoid excessive manipulation. 2 Pre-procedural imaging helps identify and avoid interposed vessels. 1, 5
Outcomes and Learning Curve
Technical success rates for EUS-HGS are 98.1% with clinical success of 98.1% in experienced hands. 7 However, the overall adverse event rate remains 14.9-23%, emphasizing the need for expertise. 4, 8, 7
The learning curve requires approximately 19-25 procedures to achieve competency. 1 Training should only commence in endoscopists experienced in EUS-FNA, wire manipulation, and biliary stent placement. 1
Recurrent biliary obstruction occurs in 15.8% of cases, primarily from stent occlusion, but re-intervention success rates are high (97.5%). 7
Post-Procedural Management
Monitor for early adverse events including peritonitis, fever, and bleeding in the first 30 days. 6, 8
The procedure-related mortality rate at 30 days is approximately 5%, with morbidity of 18%. 8
EUS-HGS should only be performed at high-volume centers with dedicated expertise in interventional EUS and immediate access to surgical backup. 1, 2