Hepaticogastrostomy (EUS-Guided Biliary Drainage)

When the bile ducts are blocked, bile cannot flow from the liver into the bowel; it passes into the blood and causes jaundice. The usual way of relieving that blockage is ERCP.

But ERCP is not always possible. If a tumour has blocked the duodenum, if earlier stomach surgery has changed the anatomy, or if the papilla cannot be reached, another route is needed.

Hepaticogastrostomy is the opening of a direct route with an endoscope between a dilated bile duct in the left lobe of the liver and the stomach. Bile begins to flow into the stomach without the blockage being relieved at all.

When is it needed?

• Obstructive jaundice where ERCP has failed technically
• The papilla being out of reach because a tumour has blocked the duodenum
• Anatomy altered by previous surgery
• A diverticulum or tumour spread around the papilla

These patients used to have a needle passed through the skin into the liver and a drain brought out (percutaneous drainage). The advantage of hepaticogastrostomy is that the bile flows inside the body rather than out of it: the patient carries no bag and loses no fluid or electrolytes.

Consent form

The clinic’s consent form will be signed.

How is it done?

An endoscope with an ultrasound probe at its tip is passed into the stomach. The dilated bile duct in the left lobe of the liver is found on the ultrasound picture, and a needle is passed into it through the wall of the stomach.

Once bile is seen to come back through the needle, a guidewire is fed into the duct, the track is widened, and a partially covered metal stent is placed between the bile duct and the stomach. The stent forms a lasting route for the flow.

What are the risks?

This is one of the most technically demanding procedures in biliopancreatic endoscopy; it has many steps and calls for experience. Reported complication rates are around 15–20%:

• Bleeding
• Bile leak and the peritonitis that can follow it
• The stent moving out of place
• Air escaping into the abdominal cavity (pneumoperitoneum)
• Infection

For that reason the procedure should be done in centres with experience in advanced endoscopy.