Echoguided hepatico-gastrostomy: a case report.

Endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage has become the gold standard procedure for decompression of obstructed biliary ducts. Skilled endoscopists are expected to achieve successful drainage in 90% to 95% of cases. However, anatomic variation, such asperiampullary diverticulum, tumor invasion and surgical diversions are all situations that may result in failure. In cases where such failure occurs, available options include repeat ERCP at a tertiary care center, percutaneous transhepatic drainage (PTD), and surgery. PTC has complication rate of up to 32%, with possible fistula formation, cholangitis, peritonitis, empyema, hematoma, and liver abscesses. Surgery, although definitive, is associated with increased morbidity and mortality. The echoguided hepatico-gastrostomy technique was first described in 2003 by Giovannini et al. and may be seen as a variation of the intrahepatic approach, but without selective drainage through the ampulla. In terms of a minimally invasive concept and low complication rate, this is the first presentation of hepatico-gastrostomy drainage using both endoscopic ultrasound and fluoroscopy guidance performed at the Gastrointestinal Endoscopy Unit in the Hospital das Clínicas – University of São Paulo School of Medicine.