VIDEO PLENARY 3: VID-THER-04: Advanced endoscopic ultrasound-guided biliogastric anastomosis and interventions

BACKGROUND: Endoscopic ultrasound (EUS)-guided biliary drainages are increasingly performed in patients with failed endoscopic retrograde cholangiopancreatography. Common approaches for transmural drainage include choledochoduodenostomy and hepaticogastrostomy (HGS). In this video, we describe three patients with difficult EUS-biliogastric anastomosis and advanced interventions through the established anastomosis. CASE REPORT: Case 1 describes a case in which a choledochogastric anastomosis was performed. A 74-year-old female presented with upper gastrointestinal bleeding with failed endoscopic hemostasis requiring surgical plication of the bleeder, closure of the pylorus and gastrojejunostomy due to a locally advanced pancreatic cancer. She then developed biliary obstruction. A EUS-guided choledochogastrostomy was then performed with a forward-viewing echoendoscope. Case 2 describes a EUS-guided salvage of a misdeployed HGS stent. EUS-guided HGS was performed in a patient with unresectable gastric cancer with pyloric obstruction. During deployment, the proximal end of the stent was deployed in to the peritoneal cavity with loss of guidewire. EUS-guided HGS was then performed to the misdeployed stent. Case 3 describes a patient with 2-staged endoscopic recanalization of a stenosed surgical hepaticojejunostomy for benign distal biliary stricture via a EUS-guided HGS. In the first stage, a EUS-guided HGS was performed through the left intrahepatic duct. The video describes the second stage of the procedure where endoscopic recanalization of the surgical hepaticojejunostomy was performed a few months later. CONCLUSION: Advanced biliogastric anastomoses and interventions were feasible and successfully avoided surgical interventions in these patients.