EUS-guided transluminal drainage for a huge perihepatic biloma covering the right hepatic lobe (with video).

An 80-year-old woman with acute cholangitis was referred to our hospital due to difficult biliary canulation. Computed tomography (CT) detected a stone with a diameter of 8 mm in the common bile duct (CBD) and a perihepatic biloma in the right hepatic lobe with a maximum diameter of approximately 14 cm [Figure 1a]. Although the CBD stone was endoscopically removed, her abdominal symptom did not improve. By using re-examination of CT, the biloma was found to become larger and cover much of the surface of the right hepatic lobe [Figure 1b], and percutaneous drainage via the hepatic parenchyma for the huge biloma was considered to be difficult. Thus, we planned to perform EUS-guided transluminal drainage on the biloma. Under EUS guidance from the duodenal bulbus, the biloma was visualized beyond the right hepatic lobe and was punctured by using a 19-gauge needle (EZ shot 3 plus: Olympus Co., Tokyo, Japan) with taking care not to puncture visible hepatic vessels by using Color Doppler imaging [Figure 2]. A 0.025-inch guidewire was advanced into the inside of the biloma through the needle, and then a 6-Fr endoscopic nasobiliary drainage (ENBD) catheter (Gadelius Medical K.K., Tokyo, Japan) was inserted into the biloma after dilatation of the hepaticoduodenostomy route with a 7 Fr catheter [Figure 3]. Over a 1-day period after the procedure, approximately 700 ml of bilious fluid drained from the ENBD catheter, and her symptoms disappeared. Finally, the regression of the biloma was confirmed using CT after EUS-guided drainage [Figure 4a and b].Figure 1: Computed tomography images showing a huge biloma lateral to the right hepatic lobe on admission (a) and 10 days after ERCP (b)Figure 2: Under EUS guidance from the duodenal bulbus, the biloma was visualized beyond the right hepatic lobe (arrowhead) and was punctured with a 19 G needleFigure 3: Fluoroscopic image of EUS-guided drainage with a 6-Fr endoscopic nasobiliary drainage catheterFigure 4: Follow-up computed tomography images showing resolution of the biloma before discharge (a) and 2 months after discharge (b)Percutaneous drainage is widely used for symptomatic bilomas,[1] whereas EUS-guided transluminal drainage for those in the left hepatic lobe has recently been reported.[2,3] In addition, EUS-guided drainage can be the alternative to the percutaneous one for selected patients with symptomatic bilomas in the right hepatic lobe [Video 1]. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.