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Page 2 of 4 Ogura et al. Mini-invasive Surg 2018;2:8 I http://dx.doi.org/10.20517/2574-1225.2017.48

A B

Figure 1. (A) Endoscopic ultrasound-guided hepaticogastrostomy using covered metal stent; (B) infected biloma is seen around
endoscopic ultrasound-guided hepaticojejunostomy stent (arrow)

patients with a history of EUS-HJS because of limited lumen space compared with the stomach. Also, due
to large diameter of EUS-HJS stent, bile juice reflux may cause vomiting. Recently, novel plastic stent has
been introduced available in Japan. The plastic stent, which is a push-type stent and usually not possible
to retract, has a total length of 20 cm, an effective length of 15 cm, and 4 flanges. The proximal end has a
[2,3]
pigtail structure to prevent stent migration and the distal end is tapered . This plastic stent has clinical
impact because it is able to prevent stent migration into the abdominal cavity.

Although EUS-guided biliary drainage, such as hepaticogastrostomy (HGS), offers an alternative method
to percutaneous transhepatic biliary drainage [2-5] , various adverse events such as stent migration into
the abdominal cavity are associated with EUS-HGS and considerable effort has been directed towards
[4,5]
preventing them . Despite these efforts, adverse events such as infected biloma after EUS-HGS still arise
due to frequent reflux cholangitis through EUS-HGS stent, or bile duct obstruction by a covered metal
[5]
[6]
stent . A longer HGS stent may help to prevent reflux cholangitis , but if infected biloma occurs around
an EUS-HGS, the stent must be exchanged. Other adverse events including liver abscess, may occur due
to various reasons, and should be treated [7-11] . Here, we describe treatment of a liver abscess around an
EUS-HGS, using double stent placement stent in an elderly man who had a history of surgery for bile duct
cancer.

CASE REPORT
A 78-year-old man who had undergone pancreaticoduodenectomy due to bile duct cancer 1 year previously,
was admitted to our hospital with obstructive jaundice. A benign bile-jejunum anastomosis stricture was
diagnosed with computed tomography. Because the patient declined to undergo percutaneous drainage, the
doctor proposed an alterative EUS-HGS procedure. The procedure was performed using a 10 mm × 10 cm,
Niti-S Biliary Covered Stent (partially-covered, TaeWoong Medical, Seoul, South Korea; Century Medical
Inc., Tokyo, Japan) [Figure 1A]. This resolved the obstructive jaundice, no adverse events occurred, and the
patient was discharged after 2 weeks.

Four weeks after the EUS-HGS procedure, the patient presented with a fever and elevated inflammatory
indicators and was consequently readmitted to hospital. Computed tomography revealed a biloma
around the EUS-HGS stent [Figure 1B]. This biloma was considered to be complicated with infection.
Endoscopic treatment for infected biloma was attempted as follows. An endoscopic retrograde
cholangiopancreatography (ERCP) catheter (MTW Endoskopie, Düsseldorf, Germany) was initially
inserted into the biliary tract through the EUS-HGS stent. A 0.025-inch guidewire (VisiGlide; Olympus
Medical Systems, Tokyo, Japan) was inserted into the catheter and the metal stent was removed through