Hepaticoduodenostomy (Right Intrahepatic Biliary Duct) Using a Lumen-Apposing Metal Stent.

Biliary decompression in cases of hilar obstruction is challenging, and the intrahepatic approach is often necessary [1]. We describe a case of endoscopic ultrasoundguided biliary drainage (EUS-BD) for unresectable hilar malignant obstruction, using lumen-apposing metal stent (LAMS). A 85-year-old woman was admitted due to abdominal pain, jaundice, and choluria. From the personal history, it is worth noting a rectovaginal septum gastrointestinal stromal tumor (GIST), treated surgically in 2002 and with imatinib for 2 years. She was also being followed for pulmonary nodules, suspected of malignancy. Abdominal computed tomography showed a 76 × 57 × 61 mm mass on the left hepatic lobe, with irregular borders, and central necrosis, suggestive of metastasis. This mass compressed the biliary tree at the hilar plaque and led to intrahepatic biliary dilatation (Fig. 1). She had portal vein invasion, pulmonary and peritoneal metastasis. Biochemical workup showed a cytocholestase pattern and total bilirubin of 26 mg/dL. The patient refused liver biopsy. After multidisciplinary discussion it was decided for an endoscopic palliative treatment. Transpapillary access through endoscopic retrograde cholangiopancreatography (ERCP) was attempted but failed due to impossibility of biliary cannulation. The procedure was performed under deep sedation. A linear echoendoscope (GF-UCT260; Olympus Medical Systems, Tokyo, Japan) was used. There was a significant intrahepatic biliary dilation (12.8 mm), and the right intrahepatic biliary duct was close enough to the duodenal bulb (5 mm), without intervening vessels (as confirmed by color doppler). As so, we performed an hepaticoduodenostomy using a 6 × 8 mm LAMS (HotAxiosTM, Boston Scientific®, Marlborough, MA, USA): under ultrasound control, the right intrahepatic biliary duct was punctured