Endosonography-guided biliary drainage (EUS-BD) can be utilized in patients with obstructive jaundice who encounter difficulties with percutaneous transhepatic biliary drainage (PTBD) and transpapillary biliary drainage. EUS-BD encompasses various drainage pathways, including endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS), endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS), endoscopic ultrasonography-guided gallbladder drainage, and the endoscopic ultrasonography-guided rendezvous technique. However, endoscopic ultrasonography-guided choledochogastrostomy (EUS-CGS) is infrequently employed. In this report, we present a case of cholangitis resulting from common bile duct stones that was successfully treated using EUS-CGS, where a stiff guidewire was used to dilate the puncture site and facilitate stent placement.

An 89-year-old woman presented to the hospital with a chief complaint of fever and hematuria. Computed tomography (CT) revealed left hydronephrosis due to bladder cancer, along with common bile duct stones and marked dilation of the bile duct (Fig. 1). Considering her advanced age, a nephrostomy was performed to treat the hydronephrosis, and endoscopic biliary stenting was attempted to treat the cholangitis; however, the scope caught on part of the stomach protruding into the thoracic cavity, perforating the mediastinum (Fig. 2). The patient was treated conservatively with gastric tube placement, followed by PTBD (i.e., placement of two pigtail-type catheters by puncture from B3 and B5). After PTBD, an attempt was made to create an internal fistula via the PTBD route; however, the procedure was difficult due to the presence of massive biliary stones measuring > 3 cm (spanning six slices on a 5-mm-slice CT scan). We also expected that transpapillary biliary drainage would be difficult; therefore, we decided to perform EUS-BD. Initially, EUS-CDS was attempted, but the common bile duct could not be visualized in close proximity to the duodenum. Instead, the gastroduodenal deformity caused the common bile duct to be in close proximity to the gastric antrum; therefore, the common bile duct was selected for puncture from the gastric antrum using a 19-gauge needle (EZ Shot 3; Olympus) (Fig. 3, 4A); however, the gastric wall and scope became separated during the dilation maneuver (Fig. 4B), making it difficult to dilate the fistula using a 6-Fr dilater (Cook Soehendra; Cook Medical) and a 4-mm-diameter balloon dilation catheter (REN; KANEKA Medix Corp.), although insertion of a tapered catheter with a 3.5 Fr tip (StarTip V, PR-V235Q; Olympus) under a 0.025-inch guidewire (VisiGlide 2; Olympus) into the bile duct was possible. The use of a stiff 0.035-inch guidewire (Wrangler; PIOLAX MEDICAL DEVICES Inc.) allowed blunt dilation up to 9 Fr with a dilator (Cook Soehendra), while simultaneously maintaining the distance between the gastric wall and the scope. Using this method, a 10-mm-diameter, 12-cm-long, partially covered metal stent (WallFlex; Boston Scientific Corp.) was deployed successfully between the common bile duct and the posterior wall of the gastric antrum (Fig. 4C–4E). The partially covered metal stent was selected to ensure bile outflow from the left and right intrahepatic bile ducts even if the hepatic side of the stent was placed immediately adjacent to the hilar plate. One month later, the percutaneous drainage tube was removed after confirming the patency of the EUS-CGS route by cholangiography, which showed that internalization by EUS-CGS was successful. There were no adverse events (e.g., bile leakage) during the period between dilator-assisted fistula dilation and stent placement or any early postoperative complications (e.g., peritonitis or bleeding).

Figure 1. (A) Computed tomography (CT) scan showing irregular thickening of the bladder wall and obstruction of the left ureter leading to hydronephrosis. (B, C) CT and magnetic resonance cholangiopancreatography show a very large common bile duct stone, with marked bile duct dilation.

Figure 2. (A) Upper endoscopy image showing laceration (red arrow) of the hiatal hernia. (B, C) Computed tomography and fluoroscopy show free air, suggesting perforation of the mediastinum.

Figure 3. Endoscopic ultrasonography images taken (A) just before and (B) at the time of bile duct puncture. Although there is some distance between the common bile duct and the stomach, the obtained endoscopic ultrasonographic images are similar to those obtained during endoscopic ultrasonography-guided choledochoduodenostomy.

Figure 4. (A) Fluoroscopy during endoscopic ultrasonography-guided choledochogastrostomy shows cholangiography after puncture of the common bile duct from the gastric wall. (B) The gastric wall and scope are separated using a 6-Fr dilater during the dilation maneuver. (C) The fistula is bluntly dilated up to 9-Fr by changing to a stiffer guidewire. (D, E) Deployment of the metal stent is completed, although the distance between the gastric wall and the scope remains throughout the procedure (up until stent placement).

Institutional and ethical approval was not required for this case report. It was exempted from the requirement for informed consent.

There are few reports on EUS-CGS.^1,2 Tsuji et al¹ described the use of EUS-CGS in a case where intraperitoneal organs were displaced into the right thoracic cavity due to Chilaiditi syndrome. The authors recommended EUS-CGS for patients with anatomical abnormalities that are difficult to treat using standard drainage techniques. Kawakubo et al² performed EUS-CGS for internalization in patients with malignant gastric outlet obstruction and/or biliary obstruction due to locally advanced cancer of the pancreatic head and who had previously undergone PTBD. Similar to our case, EUS-CDS and EUS-HGS were impossible for anatomical reasons. Although the self-expandable partially covered metal stent deployed by EUS-CGS migrated 15 days after the procedure, this was remedied by placing an additional partially covered metal stent via a fistula; thus, the EUS-CGS procedure risks separating the gastrointestinal and biliary tracts during or after the procedure. In our case, stent migration into the bile duct did not occur. One reason for this is that we used a relatively long stent (12 cm); however, after placing the guidewire into the bile duct, a distance of three vertebrae (about 10 cm) between the stomach and the common bile duct was observed fluoroscopically (Fig. 4B–4D). This gap made it impossible to pass a dilating catheter of adequate diameter through the common bile duct using a standard guidewire. In our case, the use of a stiff guidewire facilitated the successful completion of the biliary procedures, suggesting that this type of guidewire can be effectively used in challenging EUS-CGS cases that involve dilation of the fistula and stent deployment.

None.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

No potential conflict of interest relevant to this article was reported.