Unusual complications following endoscopic ultrasound-guided hepaticogastrostomy: A call for refined techniques and dedicated devices

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.

Keywords: Adverse event; Biliary drainage; Bile leak; Endoscopic ultrasound; Bilothorax

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.