LAUSR

In a patient with unresectable malignant hilar biliary obstruction (MHBO), drainage of as much liver volume as possible is recommended [1, 2]. However, the retrograde approach is difficult owing to anatomic factors or the extent of stenosis, particularly in the right posterior hepatic duct. We report a case in which endoscopic ultrasound-guided hepaticojejunostomy (EUS-HJS) of the right posterior hepatic duct allowed total liver drainage (▶Video 1). A 59-year-old woman underwent subtotal stomach-preserving pancreatoduodenectomy for ampullary carcinoma of the duodenum, and MHBO (Bismuth type 3a) due to recurrent tumor at the cholangiojejunostomy anastomosis was clinically suspected. Therefore, retrograde drainage was performed. A colonoscope was inserted into the anastomosis site (▶Fig. 1). The left hepatic duct and right anterior hepatic duct were visualized using contrast agent and guidewires were placed; however, the right posterior hepatic duct was completely obstructed and could not be approached (▶Fig. 2). Therefore, we decided that retrograde drainage was indicated for the left hepatic duct and right anterior hepatic duct, and EUS-HJS for the right posterior hepatic duct. First, fully covered self-expandable metal stents (FCSEMSs, 6mm×6cm) (EGIS braided 6; S&G Biotech Inc., Yongin-si, Korea) were placed retrogradely in the left hepatic duct and right anterior hepatic duct (▶Fig. 3). Then, a forward-viewing echoendoscope (TGF-UC260J; Olympus, Tokyo, Japan) was inserted, and the dilated right posterior hepatic duct, infraportal type, was shown near the anastomosis. This was punctured with a 19-gauge needle (EZ Shot 3 Plus; Olympus, Tokyo, Japan) and confirmed as the dilated right posterior hepatic duct by contrast enhancement (▶Fig. 4). The fistula was dilated with an electrocautery dilator (Fine025; Medico’s Hirata, Osaka, Japan), after which a FCSEMS (6mm×6cm; Hanarostent Biliary Full Cover Benefit; Boston Scientific, Tokyo, Japan) was placed (▶Fig. 5). No adverse events occurred postoperatively, and the patient was discharged 2 days later. No stent dysfunction was observed before death, which occurred 47 days after the procedure owing to exacerbation of the underlying recurrent disease. Video 1 Total liver drainage without the need for percutaneous drainage was successfully performed using transanastomotic biliary drainage combined with endoscopic ultrasound-guided hepaticojejunostomy of the right posterior hepatic duct using a forwardviewing echoendoscope.