Endoscopic Ultrasound-Guided Hepaticogastrostomy for Hilar Cholangiocarcinoma: The First Trial in Thailand
Sukij Panpimanmas MD*, Thawee Ratanachu-ek MD*
Affiliation : *Department of Surgery, Rajavithi Hospital,College of Medicine, Rangsit University, Bangkok, Thailand
Background : There are many palliative treatments for patients with unresectable malignant biliary obstruction,
e.g. endoscopic retrograde cholangiopancreatography (ERCP) with stents, percutaneous transhepatic biliary
drainage (PTBD) or surgery. We propose a new technique by using endoscopic ultrasound (EUS) with
fluoroscopy to perform hepaticogastrostomy for palliative drainage far from the site of tumor to avoid tumor
obstruction.
Material and Method: Between December 2005 and June 2006, two patients with severe jaundice by hilar
cholangiocarcinoma were treated with this new procedure. The first case was a 44-year female post partial
resection of tumor and Roux en Y hepaticojejunostomy and the second case was a 48-year male post ERCP and
right hepatic stent. We used an electronic convex curved linear-array echo-endoscope with fluoroscope
guided to drain left dilated intrahepatic duct to the stomach by inserting 8 Fr 60 mm metallic wallstent via
lesser curvature. We performed under general anesthesia and followed-up every two weeks.
Results : There were former two patients failed to place the stents. Hepaticogastrotomy of both patients were
our first successful trial but stent site of the first case was not good because the insertion was at esophagogastric
junction. Total bilirubin of first and second case fell from 38.4 mg/dl to 27.3 mg/dl and 22.0 mg/dl to 3.4 mg/
dl in two weeks, respectively. No immediate complication was found and oral diet was well succeeded on the
next day after procedure in both cases. The first case was dead after 32 days of operation from sepsis and
hepatic failure. The second case was clinically much improved after 3 months and died from liver failure after
6 months and 10 days.
Conclusion : This new interventional EUS-guided hepaticogastrostomy is safe, feasible and may provide an
alternative to surgery or PTBD or failed ERCP. It can improve the palliative treatment in hilar lesions because
it’s internal drainage and far from tumor site that promote fast recovery. However, long term study is still
necessary to evaluate the results and cost-effectiveness of this technique.
Keywords : Endoscopic ultrasound, Hepaticogastrostomy, Hilar cholangiocarcinoma
