Endoscopic retrograde cholangiopancreatography (ERCP) is the

gold standard method for biliary drainage. The alternatives

methods such as the percutaneous transhepatic biliary drainage
(PTBD) or surgery, have a higher rate of complications.

The Hepaticogastrostomy under echoendoscopy (EUS-HG)

drainage was developed since 2001 as an additional option to
PTBD and ERCP.1,2,3,4

We reported in this case, hepatico-gastrostomy for a patient

with a by-pass surgery by obesity with a new stent design.

The patient was sent to our medical center.with esophagus-

jejunal anastomosis, and with a 6 month- period of progressive
weight loss, abdominal pain, anorexia and asthenia,

A 50 mm head pancreatic mass, with mesenteric artery and vein

infiltration, was seen on the CT-scan, associated with dilatation
of the main pancreatic and the common bile ducts.
Echoendoscopy-FNA performed in a left lateral position with the
intubated patient (22G needle, Cook medical), diagnosed a
pancreatic adenocarcinoma, which reflected that the patient had
a marked jaundice and cholestasis.

A drainage by hepatico-gastrostomy was performed at the level

of the gastric stump, in a supine position. The segment III was
punctured and a partially covered 9 cm HANARO stent of length,
designed by MI tech with the association of Dr. Poincloux, was
inserted. The patient was discharged after one night of
hospitalization and received chemotherapy 15 days later (4
cycles of Folfirinox).

DISCUSSION
Patients with altered anatomy represents a challenge to biliary
drainage. Deep enteroscopy-assisted ERCP for Roux-en-Y gastric
has a success rate of 63% that depends on the length of the roux
limb.5

By-pass surgery with excluded stomach is a new challenge for

biliary drainage. ERCP through a surgically created gastrostomy
into the excluded stomach could allow to achieve ERCP in 60% of
cases.6

Another drainage in two steps with the first creation of a trans-

gastric fistula to access the papilla with a duodenoscope was
recently described.7

In our case the drainage with EUS-HG represents a new

indication of EUS-HG (not described yet after gastric by-pass
surgery) and has the advantage to be performed in one step. The
design of this new stent probably facilitates this drainage with a
long covered part (6cm) and flap to avoid migration.

1. Giovannini M, Moutardier V, Pesenti C, et al. Endoscopic

ultrasound-guided bilioduodenal anastomosis: A new technique
for biliary drainage. Endoscopy. 2001; 33: 898-900.

2. E. Bories, C. Pesenti, F. et al. Transgastric endoscopic

ultrasonography-guided biliary drainage: results of a pilot study.
Endoscopy 2007; 39: 287-291.

3. Poincloux Laurent et al. Endoscopic ultrasound-guided biliary

drainage after failed ERCP: Cumulative experience of 101
procedures at a single center. Endoscopy 2015; 47: 794-801.
4. Ratone JP, Caillol F, Bories E, Pesenti C, Godat S, Giovannini M.
Hepatogastrostomy by EUS for malignant afferent loop
obstruction after duodenopancreatectomy.Endosc Ultrasound.
2015 Jul-Sep; 4 (3): 250-2.

5. Shah RJ, Smolkin M, Yen R, et al. A multicenter, U.S.

experience of single-balloon, double-balloon, and rotational
overtube-assisted enteroscopy ERCP in patients with surgically
altered pancreaticobiliary anatomy. Gastrointest Endosc 2013;
77: 593-600.

6. Kedia P, Tyberg A et al. EUS-directed transgastric ERCP for

Roux-en-Y gastric bypass anatomy: a minimally invasive
approach. Gastrointest Endosc. 2015 Sep; 82 (3): 560-5.

7. Ngamruengphong S, Grandson J, Kunda R, Kumbhari V, Chen

YI, Bukhari M, El Zein MH, Good RP, Hajiyeva G, Ismail A, Chavez
YH, Khashab MA. Endoscopic ultrasound-guided creation of a
transgastric fistula for the management of hepatobiliary disease
in patients with Roux-en-Y gastric bypass.Endoscopy. 2017 Jun;
49 (6): 549-552.