Ingrown and exteriorized hilar tumor through hepaticogastrostomy stent causing upper gastrointestinal bleeding (with video)

Interventional EUS has evolved rapidly in recent years, with a variety of therapeutic procedures, including EUS-guided biliary drainage (EUS-BD). With the development of new tools and techniques, this procedure has become more effective, safer, and simpler, which is recommended in case of failure of conventional procedures such as ERCP.[¹²]

A 69-year-old male diagnosed with unresectable malignant hilar biliary obstruction (MHBO) presented with recurrent biliary obstruction (RBO). Fourteen months ago, the patient had MHBO and was treated with bilateral self-expandable metal stents (SEMS) (side-by-side manner), and another 10 mm × 120 mm partially covered SEMS (GIOBOR; Taewoong-Medical Co, Seoul, South Korea) as a hepaticogastrostomy (HGS) stent drained from intrahepatic bile duct (IHD) segment 3. Subsequently, the patient had percutaneous biliary drainage drained from IHD segments 7 and 8 [Figure 1a-d]. In this visit, the patient presented with melena and obstructive jaundice suspected for RBO. An emergency gastroscopy revealed tumor ingrown through intact HGS stent and exteriorized into the gastric lumen with blood clot, responsible for bleeding [Figure 2 and Video 1].

Figure 1: Biliary drainage. (a) Cholangioscopy showed malignant hilar stricture; (b) Two uncovered self-expandable metal stents were placed side-by-side; (c) a 10 mm × 120 mm partially covered self-expandable metal stents (GIOBOR; Taewoong-Medical Co, Seoul, South Korea) as a hepaticogastrostomy stent drained from intrahepatic bile duct segment 2 and 3; (d) fluoroscopic view showed a combination of a self-expandable metal stent placed by EUS-hepaticogastrostomy procedure, two self-expandable metal stents placed by endoscopic retrograde cholangiopancreatography and a plastic tube placed by percutaneous biliary drainage procedure

Figure 2: Tumor grown on hepaticogastrostomy stent in the gastric lumen

EUS-HGS was known to have advantage over the ERCP drainage in terms of longer stent patency time by avoiding the risk of tumor ingrown with reported stent patency up to 402 days.[³] To our best knowledge, this is the first case report of tumor gown within an HGS stent and went into the intragastric part of the stent, causing upper gastrointestinal bleeding after a period of 425 days from the index EUS-HGS. Hence, MHBO which is sufficiently drained by a combination of endoscopic and radiological approach, provide long survival to the patient, allowing tumor to grow inward through HGS stents.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

Pradermchai Kongkam is an Editorial Board Member of the journal. This article was subject to the journal’s standard procedures, with peer review handled independently of this editor and her research group.