Endoscopic ultrasound-guided hepaticogastrostomy drainage of an excluded left hepatic lobe in a hybrid way with percutaneous assistance

A 48-year-old woman was referred for the management of an excluded left hepatic lobe (LHL) with recurrent cholangitis after right hepatectomy extended to the segment 1 and wedge resection of the segment 2 for the treatment of an occlusive metastatic adenocarcinoma of the sigmoid colon previously treated with neoadjuvant chemotherapy and local resection. The crossing of the stricture of the left intrahepatic bile ducts (LIHBDs) was not successful with endoscopic retrograde cholangiopancreatography (ERCP). A permanent percutaneous external biliary drainage was performed through segment 3 biliary branch, complicated with pain and bile leakage around the drain. A first attempt by endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) did not succeed given the absence of dilation of the LIHBD and mostly due to an unstable position induced by a small size of the remnant LHL. Then, a hybrid procedure was performed after changing the percutaneous drain for a 5Fr Arrow-Flex introducer that permitted the puncture of the external part of the introducer with an EUS transgastric EchoTip® 19G needle and insertion of a 0.025-inch guidewire directly into the LIHBD around the introducer. The introducer was removed and the guidewire was caught in the hepatic segment 2 by a percutaneous lasso to stabilize the 0.025-inch guidewire. An EUS-HGS was done after fistulization of the transhepatic tract by 6Fr cystotome and placement of a partially-covered self-expandable metal stents. The clinical course was uncomplicated under vancomycin for an Enterococcus faecium bacteremia, and then chemotherapy was restarted. EUS-HGS is clearly established as an alternative technique for biliary drainage in case of unsuccessful ERCP or altered anatomy, based on decisional algorithm, with a pooled technical success rate of 82%, clinical success rate of 97%, and adverse event rate of 23%. The success of this procedure depends on several factors and tips like the kind and length of the intragastric part of the prosthesis, angulation of the LIHBD, oversized dilation of the transhepatic tract, access to the liver segment 3, and shearing of the guidewire. The low volume of the LHL may also be a cause of technical failure that can be resolved by new procedures as described in this case.