P-THER-24: Endoscopic ultrasound-guided biliary drainage in an operated case of right extended hepatectomy with secondaries causing hilarious obstruction

A 55-year-old male patient presented with complaints of increasing jaundice with itching and low-grade fever. He had undergone right extended hepatectomy 6 months back for right lobe hepatocellular carcinoma. Investigations revealed a total count of 9200/cumm, a bilirubin level of 18.6 mg/dl, and serum glutamic-pyruvic transaminase of 72 IU/L. Ultrasonography done revealed multiple para-aortic nodes and dilated left duct and intrahepatic biliary radical (IHBR). Computed tomography (CT) scan revealed multiple nodes at the area of the original confluence pressing of the left duct with dilatation of the left duct and IHBR. CT revealed a bowel loop near the hilum suggestive of end of jejunum to side of the left duct anastomosis with a tight narrowing at that level. We planned to palliate the patient with an endoscopic ultrasound (EUS)-guided hepaticogastrostomy. EUS was attempted with an intent to do a left duct drainage into the stomach with a Giobor stent. B3 radicle was carefully selected and puncture was made with a 19-gauge needle. The contrast did not go beyond the hilum. A Terumo guide wire was introduced and luckily the wire went into the distal common bile duct. This suggested that the hepaticojejunostomy was done end to side to the hilum. Hence, we now got the wire out of the papilla and performed a rendezvous procedure draining the left duct in the duodenum as this is much safer procedure than a hepaticogastrostomy. The patient was kept nil orally for 6 h and then on liquids for 24 h and diet started.