PMC8352689_01
(a-c) EUS-guided hepaticoesophagostomy in a 57-year-old patient with an irresectable tumor of the pancreatic head and left hepatic lobe hypertrophy.
CRIGM2021-4639286.001.jpg
PMC8352689_01_CRIGM2021-4639286.001.jpg
fig1
During the endoscopic examination, with no possibility of transpapillary palliative biliary drainage, the patient underwent transmural drainage of the biliary duct by establishing extra-anatomic anastomoses (Figures 1(a)-1(c)). Next, the contrast agent was administered via the intraductal needle under fluoroscopic control to obtain an antegrade cholangiogram (Figure 1(a)). Taewoong Medical, Gyeonggi-do, Korea) was introduced through the newly formed fistula under endosonographic and fluoroscopic guidance (Figures 1(b) and 1(c)). The catheter was then introduced through the endoprosthesis into the bile duct, and a contrast agent was administered for a follow-up cholangiographic examination to confirm correct positioning of the transmural endoprosthesis, correct biliary drainage, and the absence of any leaks from the biliary tract.
(a-c) Late complication of endoscopic treatment in the form of biliopleural fistula. Right pleural cavity drainage.
CRIGM2021-4639286.002.jpg
PMC8352689_01_CRIGM2021-4639286.002.jpg
fig2
Twenty four days after the endoscopic procedure, the patient was admitted again to our department due to symptoms related to fluid in the right pleural cavity (Figures 2(a) and 2(b)). Basing on the clinical image and results of imaging examinations, the late complication of EUS-HES:transmural stent migration resulting in biliopleural fistula and bile leaking into the right pleural cavity:was diagnosed (Figures 2(a)-2(c)). The patient required drainage of the right pleural cavity (Figures 2(a) and 2(b)).
Endoscopic treatment of biliopleural fistula as a complication of endoscopic hepaticoesophagostomy
CRIGM2021-4639286.003.jpg
PMC8352689_01_CRIGM2021-4639286.003.jpg
fig3
This complication was successfully managed endoscopically (Figure 3). Scientific Corp., Marlborough, Massachusetts, USA) was introduced into biliary ducts. By the use of guidewire, across the dislocated transmural stent, another biliary self-expanding metal stent (using "nstent-in-stent" technique) with a diameter of 10 mm and length of 8 cm (Evolution  Biliary Controlled-Release Stent-Partially Covered, Cook Endoscopy, Ireland) was introduced and esophagobiliary anastomosis was splinted via the right pleural cavity (Figure 3). Seven days after the procedure, the patient was discharged home in good general condition without any symptoms to continue the oncological treatment.