Choi JH, Paik WH. Unusual complications following endoscopic ultrasound-guided hepaticogastrostomy: A call for refined techniques and dedicated devices. World J Gastroenterol 2025; 31(43): 113186 [DOI: 10.3748/wjg.v31.i43.113186]
Corresponding Author of This Article
Woo Hyun Paik, MD, PhD, Professor, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro 101, Seoul 03080, South Korea. iatrus@snu.ac.kr
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Letter to the Editor
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastroenterol. Nov 21, 2025; 31(43): 113186 Published online Nov 21, 2025. doi: 10.3748/wjg.v31.i43.113186
Unusual complications following endoscopic ultrasound-guided hepaticogastrostomy: A call for refined techniques and dedicated devices
Jin Ho Choi, Woo Hyun Paik
Jin Ho Choi, Woo Hyun Paik, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea
Author contributions: Paik WH and Choi JH wrote and revised the manuscript.
Conflict-of-interest statement: There is no conflict of interest associated with any of the senior author or other coauthors contributed their efforts in this manuscript.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Woo Hyun Paik, MD, PhD, Professor, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro 101, Seoul 03080, South Korea. iatrus@snu.ac.kr
Received: August 19, 2025 Revised: September 23, 2025 Accepted: October 20, 2025 Published online: November 21, 2025 Processing time: 94 Days and 1.1 Hours
Abstract
We read with great interest the case report by Zhang et al describing unusual complications after endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) in a patient with pancreatic cancer. The patient developed dark green urine, bile-colored pleural effusion, and ascites, suggesting bile leak and possible biliary-vascular fistula. We believe the complication profile is more consistent with transdiaphragmatic bile leakage during segment 2 puncture, as microperforation near the diaphragm can explain bilothorax. Device selection for fistula dilation and stent type may also have contributed. High pleural fluid-to-serum bilirubin ratios further support the diagnosis of bile leak, with urinary discoloration likely reflecting systemic absorption. This rare case highlights the need for refined techniques, careful puncture site selection, and dedicated devices to enhance safety in EUS-HGS.
Core Tip: Unusual complications following endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) underscore the need for careful attention to technique and device choice. Although plastic stents are still used, fully covered self-expandable metal stents may better prevent bile leakage. Additionally, the choice of puncture site, such as segment 2 vs segment 3, and the method of fistula dilation critically influence outcomes. This editorial highlights the importance of refining EUS-HGS techniques and developing dedicated devices to enhance safety and reduce unexpected complications.
