Clinical Endoscopy

Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy for biliary drainage in hypervascular hepatocellular carcinoma: a retrospective study from Japan: Kenneth Tachi, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Ahmed Mohammed Sadek, Hossam El-Din Shaaban Mahmoud Ibrahim, Minako Urata, Takashi Kondo, Yoshitaro Yamamoto; Received April 2, 2024 Accepted July 29, 2024 Published online November 11, 2024; DOI: https://doi.org/10.5946/ce.2024.079 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Biliary obstruction drainage in patients with hepatocellular carcinoma (HCC) is associated with symptom palliation, improved access to chemotherapy, and improved survival. Stent placement and exchange via endoscopic retrograde cholangiopancreatography biliary drainage risk traversing the HCC, a hypervascular tumor and causing bleeding. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) potentially prevents procedure-related bleeding. Therefore, we evaluated the efficacy and safety of EUS-HGS as an alternative treatment for biliary obstruction in patients with HCC.
Methods
This was a retrospective study of all EUS-HGS procedures performed in patients with HCC at the Aichi Cancer Center Hospital, Japan, from February 2017 to August 2023.
Results
A total of 14 EUS-HGS procedures (42.9% primary) were attempted in 10 HCC patients (mean age 71.5 years, 80.0% male). Clinical and technical success rates were 92.9% and 90.9%, respectively. The observed procedure details in the 13 successful procedures included B3 puncture (53.8%), 22-G needle (53.8%), fully covered self-expandable metal stent (100%), and mean procedure time (32.7 minutes). There was no bleeding. Mild complications occurred in 27.3%. All patients resumed oral intake within 24 hours.
Conclusions
EUS-HGS is a technically feasible and clinically effective initial or salvage drainage option for the treatment of biliary obstruction in patients with HCC.

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Role of Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Portal Vein Thrombus in the Diagnosis and Staging of Hepatocellular Carcinoma: Dina Eskandere, Hazem Hakim, Magdy Attwa, Wagdi Elkashef, Ahmed Youssef Altonbary; Clin Endosc 2021;54(5):745-753. Published online March 15, 2021; DOI: https://doi.org/10.5946/ce.2020.240

Background
/Aims: Malignant portal vein thrombus (PVT) is found in up to 44% of patients with hepatocellular carcinoma (HCC). The nature of the thrombus influences treatment selection. The aim of this study was to assess the safety and efficacy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in determining the nature of PVT in liver cirrhosis and/or HCC.
Methods
A prospective study was conducted in 34 patients with liver cirrhosis and/or HCC with PVT. Under EUS guidance, PVT was punctured using a 22 G FNA needle (Cook Medical, Bloomington, IN, USA) followed by monitoring of the puncture tract using color Doppler. Patients were followed for adverse events 2 hours after recovery.
Results
Throughout the 30-month study period, 34 patients, including 24 males with a mean age of 59±8 years, were enrolled. There were 8 patients with known HCC and 26 with no liver masses detected by computed tomography (CT). EUS-FNA from PVT was positive for malignancy in 3 patients (8.8%), of which only 1 patient was diagnosed with HCC by CT and 2 patients were newly diagnosed with HCC after EUS-FNA. No major complications were reported.
Conclusions
EUS-FNA is a safe and effective technique for determining the nature of PVT that does not fulfill the malignant criteria via imaging studies in patients with liver cirrhosis and/or HCC.

Citations

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Endoscopic ultrasound–guided vascular interventions: A review (with videos)
Praveer Rai, Pankaj Kumar, Umair Shamsul Hoda, Kartik Balankhe
Indian Journal of Gastroenterology.2024; 43(5): 927. CrossRef
Endoscopic ultrasound-guided vascular interventions: An overview of current and emerging techniques
Ahmed Youssef Altonbary
International Journal of Gastrointestinal Intervention.2023; 12(1): 16. CrossRef
Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy
Irina Dragomir, Cristina Pojoga, Claudia Hagiu, Radu Seicean, Bogdan Procopet, Andrada Seicean
Gastroenterology Report.2023;[Epub] CrossRef

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A Case of a Patient Presenting with Upper Gastrointestinal Bleeding Due to Direct Stomach Invasion by Hepatocellular Carcinoma: Joon Mo Park, M.D. and Dong Hee Kim, M.D.; Korean J Gastrointest Endosc 2010;41(4):232-235. Published online October 30, 2010

Abstract PDF: Gastrointestinal bleeding is a common complication of hepatocellular carcinoma, and the most common causes are esophageal varix, gastric varix and a bleeding ulcer. Hepatocellular carcinoma rarely invades the gastrointestinal tract, and this has been shown to occur in 0.7∼2% of the clinical hepatocellular carcinoma cases. A 52-year old male who had a history of a huge hepatocellular carcinoma on the left lobe of the liver and this had been by chemoembolization was admitted due to hematemesis and melena. Esophagogastroduodenoscopy showed a huge fungating mass with easy contact bleeding in the lesser curvature of the gastric body. The histology was consistent with the diagnosis of metastatic hepatocellular carcinoma and results of the CT scan supported this finding. This case illustrates a rare event of direct invasion of hepatocellular carcinoma into the stomach and this was followed by gastrointestinal hemorrhage. (Korean J Gastrointest Endosc 2010;41:232-235)

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A Case of Duodenobiliary Fistula Caused by a Metal Stent in a Patient with Hepatocellular Carcinoma: Seok Bae Yoon, M.D., Hong Sik Lee, M.D., Hyuk Soon Choi, M.D., Hye Jin Cho, M.D., Tae Jung Yun, M.D., Jin Nam Kim, M.D., Ik Yoon, M.D. and Chang Duck Kim, M.D.; Korean J Gastrointest Endosc 2009;39(5):324-327. Published online November 30, 2009

Abstract PDF: Biliary drainage can improve the quality of life in a patient with obstructive jaundice caused by malignancy. Biliary metal stent insertion is a very useful method because it drains the bile physiologically and patients have little discomfort with the procedure. It has a few complications such as restenosis, liver perforation, bowel perforation, fistula formation and stent dislocation. Perforation and fistula formation are caused by pressure due to the self expanding characteristics of the metal stent. We report here on a case of duodenobiliary fistula that was caused by a biliary metal stent in a patient suffering with hepatocellula carcinoma, and we also include a review of the relevant literature. (Korean J Gastrointest Endosc 2009; 39:324-327)

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Common Bile Duct Obstruction Caused by Tumor Thrombus after Trans-arterial Chemoembolization in a Hepatocellular Carcinoma Patient: Hoon Choi, M.D., Suk Bae Kim, M.D., Ki Chul Shin, M.D., Hyun Duk Shin, M.D., Se Young Yun, M.D., Jung Eun Shin, M.D., Hong Ja Kim, M.D. and Il Han Song, M.D.; Korean J Gastrointest Endosc 2009;38(5):299-302. Published online May 30, 2009

Abstract PDF: The jaundice in hepatocellular carcinoma patient can be found when the tumor progresses or hepatic function deteriorates. Rarely, it can be occurred when the bile duct is obstructed. The main reason of obstructive jaundice in hepatocellular carcinoma is bile duct invasion of tumor, tumor thrombus, blood clot of hemobilia and direct bile compression by tumor or metastatic lymph node. Although the tumor thrombi among them is difficult to think, prompt diagnosis and treatment should be done because the symptom and prognosis can be improved by removal of the tumor thrombus. We experienced a case of hepatocellular carcinoma patient associated with obstructive jaundice caused by tumor thrombus after transarterial chemoembolization (TACE). The tumor thrombus was removed by endoscopic retrograde cholangiopancreatography (ERCP) and confirmed as degenerated hepatocellular carcinoma cell. (Korean J Gastrointest Endosc 2009;38:299-302)

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Upper Gastrointestinal Bleeding due to Direct Invasion of Hepatocellular Carcinoma to the Duodenum: Kyoung Ah Jung, M.D., Hyun Jin Kim, M.D., Sun Pil Choi, M.D., Jong Ha, M.D., Byong Ryol Lim, M.D., Tae Hyo Kim, M.D. and Ok Jae Lee, M.D.; Korean J Gastrointest Endosc 2006;33(5):298-302. Published online November 30, 2006

Abstract PDF: Although a metastasis to the gastrointestinal tract (GI) is rare in patients with hepatocellular carcinoma (HCC), it can occur by hematogenous or lymphatic spread, or by direct invasion of a tumor. A 61-year old woman who had a progressing large primary liver cancer presented with upper gastrointestinal (UGI) bleeding. UGI endoscopy showed a large duodenal submucosal tumor-like mass with a central ulcer and adherent blood clots. Endoscopic biopsy and coagulation using argon plasma probe were performed. The microscopic examination revealed a HCC. We report this unusual case of HCC with direct invasion of the duodenum. (Korean J Gastrointest Endosc 2006;33:298⁣302)

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A Case of Hepatocellular Carcinoma Invading Intrahepatic Duct Complicated by Hemobilia: Soo-Jeong Cho, M.D., Ji Kon Ryu, M.D., Sun-Jung Myung, M.D., Cheol Min Shin, M.D., Dong Won Ahn, M.D., Su Jong Yu, M.D., Ji-Won Yu, M.D., Jin Ho Paik, M.D.*, Gyeong Hoon Kang, M.D.* and Hyo-Suk Lee, M.D.; Korean J Gastrointest Endosc 2005;31(4):278-280. Published online October 30, 2005

Abstract PDF: A seventyone-year-old male presented with sudden epigastric pain followed by jaundice and intermittent right upper abdominal pain. He was diagnosed as hepatocellular carcinoma 7 years ago, and has been treated with transarterial chemoembolization, percuaneous ethanol injection and segmentectomy. On admission, the level of serum bilirubin, amylase and lipase were 8.7 mg/dL, 560 IU/L, and 13,297 IU/L, respectively. Stool occult blood test was positive. Abdominal computed tomography revealed newly- appeared intraductal soft tissue mass with ductal dilatation. Endoscopic retrograde cholangiography demonstrated filling defects in the common hepatic and distal common bile duct (CBD). Endoscopic sphincterotomy was performed and the clots in the distal CBD were removed. An intraductal stent was inserted at the common hepatic duct. The obstructive jaundice and pancreatitis were resolved. Our case suggests that intraductal hepatocellular carcinoma may induce hemobilia as a possible cause of acute pancreatitis. (Korean J Gastrointest Endosc 2005;31:278⁣281)

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Efficacy of Percutaneous Cholangioscopic Ethanol Injection in Hepatocellular Carcinoma Invading the Bile Duct: Jung Min Choi, M.D., Sung Koo Lee, M.D., Sang Soo Lee, M.D., Jang Han Lee, M.D., Moon Hee Song, M.D., Dae Keun Pyun, M.D., Tae Jun Song, M.D., Jung Sik Choi, M.D., Do Hyun Park, M.D., Dong Wan Seo, M.D., Myung Hwan Kim, M.D. and Young Il Min, M.D.; Korean J Gastrointest Endosc 2005;30(6):305-311. Published online June 30, 2005

Abstract PDF: Background
/Aims: To evaluate the clinical outcomes of the percutaneous cholangioscopic ethanol injection in the hepatocellular carcinoma (HCC) invading the bile duct, we conducted a retrospective study. Methods: Ten patients who received the percutaneous cholangioscopic ethanol injection were selected patients were diagnosed as HCC invading the bile duct between January 1998 and February 2004. Treatment response, complications, survival or death and survival time were analyzed. Results: Ten patients received mean of 5.3 sessions (range 2∼19) of cholangioscopic ethanol injection. Eight patients had decreased tumor mass, and the rest 2 patients had no response. Complications were pain (n=10), hemobilia (n=6: bleeding was minimal), cholangitis (n=2), bile duct rupture (n=1), and bile duct stricture (n=1). Nine patients died from severe hepatic failure and sepsis, one patient has survived for 19 months as of now. Median survival time was 5 months (range 2∼19 months). Percutaneous transhepatic biliary drainage (PTBD) could be removed in two patients. Conclusions: Percutaneous cholangioscopic ethanol injection in HCC invading the bile duct showed size reduction of mass. PTBD could be no longer needed in some patients. However, supportive cares such as PTBD may be appropriate considering their short survival period and risk of procedure. (Korean J Gastrointest Endosc 2005;30: 305⁣311)

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증례 / 담도경을 통한 알코올 주입술이 유용했던 활달형 간세포암 ( Icteric Type Hepatocelluar Carcinoma for Which Cholangioscopic Ethanol Injection Was Effective ): Korean J Gastrointest Endosc 2001;22(3):187-191. Published online November 30, 2000

Abstract PDF: Hepatocellular carcinoma often invades the portal or hepatic veins, but rarely proliferates in the bile duct. Since curative resection is rarely possible in these cases, conservative therapy has been the sole modality. Herein, we report a case of icteric type hepatocellular carcinoma for which cholangioscopic ethanol injection was effective. By only transcatheter arterial chemoembolization in this patient, obstructive jaundice and intermittent cholangitis were not relieved. Therefore, we performed ethanol injection into the intraductal hepatoma mass under percutaneous transhepatic cholangioscopic guidance. As a result of therapy, he had been well without jaundice and cholangitis for 9 months until die. (Korean J Gastrointest Endosc 2001;22:187 - 191)

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간세포암을 동반한 담관 낭종 1예 ( A Case of a Choledochal Cyst Combined with a Hepatocellular Carcinoma ): Korean J Gastrointest Endosc 2000;20(2):149-153. Published online November 30, 1999

Abstract PDF: A choledochal cyst is relatively rare lesion in the biliary system, and a carcinoma arising from such a cyst is rarely reported. Until now, a case of a hepatocellular carcinoma combined with a choledochal cyst had not been reported. A 45-year-old woman was recently admitted due to abdominal pain. An abdominal computed tomography revealed a 5 cm-sized low attenuative mass involving the right anterior and left medial segment of the liver and gallbladder fossa. An endoscopic retrograde cholangiopancreatogram showed fusiform dilatation of the common bile duct, but anomalous union of pancreaticobiliary duct was not observed. Fine-needle aspiration of the liver was conducted and yielded a hepatocellular carcinoma. On celiac arteriography, a hypervascular hepatic mass was also found. Transarterial chemoembolization was performed. It is believed this may be the first case of a choledochal cyst combined with a hepatocellular carcinoma in the literature. Hence, this case is herein reported with a review of related literatures.

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간세포암의 십이지장침윤에 의한 상부위장관 출혈 1 예 (A Case of Hepatocellular Carcinoma with Duodenal Invasion and Bleeding): Korean J Gastrointest Endosc 1999;19(2):267-274. Published online November 30, 1998

Abstract PDF: Recent advances in both the diagnosis and treatment of hepatocellular carcinoma have improved the prognosis and changed the clinical significance of the recently increasing distant metastases. Distant metastases found after successful treament of the primary lesions are of great clinical significance for the treatment of hepatocellular carcinoma. The duodenum is a rare site of hematogenous metastases or direct invasion from hepatocellular carcinoma. A 23 year old man was admitted with upper gastrointestinal bleeding. He had been diagnosed with hepatocellular carcinoma and treated by a left lobectomy and chemoembolization. The patient was admittted for 12 months after the treatment of the primary tumor. Endoscopic examination revealed a mass in the duodenal bulb that protruded into the lumen. He died due to massive hematemesis. We report on a rare case of hepatocellular carcinoma with duodenal invasion in a 23-year-old male patient. (Korean J Gastrointest Endosc 19: 267 ∼272, 1999)

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증례 : 위장관 ; 간세포암과 병발한 임상적으로 진단된 궤양성 대장염 1예 ( Case Reports : Stomach & Intestine ; A Case of Clinical Ulcerative Colitis with Concurrent Hepatocellular Carcinoma ): Korean J Gastrointest Endosc 1997;17(5):696-701. Published online November 30, 1996

Abstract PDF: Ulcerative colitis is a diffuse inflammatory disease which is characterized by the vascular congestion and superficial ulcerations in the mucosal and the submucosal layers of the rectum and colon. Extraintestinal manifestations such as arthritis, skin lesion, hepatobiliary and ocular diseases occur in a large number of patients with ulcerative colitis, though gastrointestinal symptoms of mucous and bloody stool, diarrhea and abdominal pain are frequently presented. The association of ulcerative colitis and hepatobiliary disease has been frequently reported in the western countries since the first description by Thomas C.H. in 1874. Fatty degeneration, chronic active hepatitis, cirrhosis, primary sclerosing cholangitis and hepatobiliary carcinoma are included in this list of complications. In the case of hepatobiliary carcinoma, however, the histological diagnosis has almost invariably been cholangiocarcinoma. We report a case of clinical ulcerative colitis with coneurrent hepatocellular carcinoma confirmed by the histologic examination of biopsy specimen in a 49 year old man with the relevant literatures. (Korean J Gastrointest Endosc 17: 696-701, 1997)

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증례 : 식도 위장관 ; 상부 위장관 출혈을 야기한 십이지장에 전이된 간세포성 간암 1예 ( Case Reports : Esophagus , Stomach & Intestine ; A Case of Duodenal Metastasis of Hepatocellular Carcinoma Presenting Gastrointestinal Bleeding ): Korean J Gastrointest Endosc 1996;16(5):749-755. Published online November 30, 1995

Abstract PDF: Extrahepatic metastasis of Hepatocellular carcinoma(HCC) to the gastrointestinal tract is uncommon. Because most of metastases to the gastrointestinal tract have no clinical manifestations, they are usually found incidentally at the time of an autopsy or a laparotomy, We experienced a case of duodenal metastasis of HCC, which presented UGI bleeding. A 59 years old male was admitted to our hospital due to generalized jaundice, which lasted for about a week. From the third day of admission, he had episodes of hematemesis and melena. An abdoinal CT scan demonstrated multiple, variable sized low-density masses in the entire liver with portal vein thrombosis and conglomerated lymph nodes. An esophagogastroduodenoscopy showed a protruded submucosal mass-like lesion with multiple ulceration in the duodenal bulb. We confirmed the duodenal mass-like lesion to be hepatocellular carcinoma by a biopsy and a histoimmunochemical study. (Korean J Gastrointest Endosc 16: 749~754, 1996)

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증례 : 담도 췌장 ; 담도경검사법 ( Cholangioscopy ) 으로 확진된 폐쇄성황달을 동반한 간세포암 3예 ( Case Reports : Biliary Tract & Pancreas ; Hepatocellular Carcinoma with Obstructive Jaundice Confirmed by Percutaneous Transhepatic Cholangioscopy ( PTCS ) and Peroral Cholangioscopy ( POCS ) ): Korean J Gastrointest Endosc 1996;16(4):681-691. Published online November 30, 1995

Abstract PDF: Jaundice associated with hepatocellular carcinoma usually occurs in the later stages due to the advanced underlying liver cirrhosis or tumor infiltration of the liver parenchyme. In the rare cases, obstructive jaundice presents as the ininitial manifestation of hepatocellular carcinoma. The possible mechanisms of bile duct obstruction associated with hepatocellular carcinoma include extrinsic compression of bile duct by extensive tumor infiltration of the liver or enlarged lymph node, direct tumor invasion of the biliary duct system, and bile duct obstruction by tumor thrombus, necrotic debris, or blood clots. We experienced three cases with hepatocellular carcinoma in whom obstructive jaundice were caused by intraductal involvement of the tumor, which were confirmed by percutaneous transhepatic cholangioscopy(PTCS) and peroral cholangioscopy(POCS). PTCS and POCS finding showed multiple, irreguarly shaped, yellowish soft tissue(chicken fat) and blood clots and, round protruded mass in the ble duct. Biopsy specimens revealed pathologically hepatocelluar carcinoma. (Korean J Gastrointest Endosc 16: 681-689, 1996)

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경구적 담관내시경검사로 진단된 총간관내 원발성간암의 종양색전에 의한 폐쇄성 황달 1예 ( Obstructive Jaundice Caused by the Fragment of Hepatocellular Carcinoma in the Common Hepatic Duct Confirmed by Peroral Choledochoscopy ): Korean J Gastrointest Endosc 1993;13(2):415-418. Published online November 30, 1992

Abstract PDF: The causes of jaundice in patients with hepatocellular carcinoma are usually attributed to the underlying liver diseases or extensive hepatic destruction by tumor. Obstructive jaundice by the intraluminal tumor fragment of intrahepatic and/or extrahepatic bile duct in hepatocellular carcinoma is exceedingly rare and usually diagnosed by operation or autopsy. Recently, we observed a patient in whom the fragment of tumor from the primary hepatocellular carclnoma obstructed the common hepatic duct, which was confirmed by peroral choledochoscopy. Using peroral choledochoscopy. we could see the mass located at the common hepatic duct and diagnose histologically by cytologic examination of aspirated material of common bile duct. We describe here this rare case with review the literature on primary hepatocellular carcinoma with jaundice caused by biliary obstruction.

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