Clin Endosc.  2024 Sep;57(5):656-665. 10.5946/ce.2023.244.

Puncture angle on an endoscopic ultrasound image is independently associated with unsuccessful guidewire manipulation of endoscopic ultrasound-guided hepaticogastrostomy: a retrospective study in Japan

• Ohno A
• Fujimori N
• Kaku T
• Matsumoto K
• Murakami M
• Teramatsu K
• Ueda K
• Hijioka M
• Aso A
• Ogawa Y

• KMID: 2559217
• DOI: http://doi.org/10.5946/ce.2023.244

Abstract

Background/Aims
Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is performed globally, the procedure remains challenging. Guidewire manipulation is the most difficult step, and there are few reports on the factors associated with unsuccessful guidewire manipulation. This study aimed to assess the significance of the puncture angle on EUS images and identify the most effective guidewire rescue method for patients with unsuccessful guidewire manipulation.
Methods
We retrospectively enrolled 115 patients who underwent EUS-HGS between May 2016 and April 2022 at two centers. The puncture angle between the needle and the intrahepatic bile duct was measured through EUS movie records.
Results
Guidewire manipulation was unsuccessful in 28 patients. Receiver operating characteristic (ROC) curves identified an optimal puncture angle cutoff value of 85° (cutoff value, 85°; area under the ROC curve, 0.826; sensitivity, 85.7%; specificity, 81.6%). Multivariate analysis demonstrated that a puncture angle <85° was a significant risk factor for unsuccessful guidewire manipulation (odds ratio, 19.8; 95% confidence interval, 6.42–61.5; p<0.001). Among the 28 unsuccessful cases, 24 patients (85.7%) achieved successful guidewire manipulation using various rescue methods.
Conclusions
The puncture angle observed on EUS is crucial for guidewire manipulation. A puncture angle of <85° was associated with unsuccessful guidewire manipulation.

Keyword

Bile ducts; Biliary tract; Endoscopic ultrasound; Guidewire; Interventional

Figure

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  Fig. 1. Flow chart of the study participants. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; AG, antegrade; IHBD, intrahepatic bile duct.

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  Fig. 2. Flow chart of the rescue guidewire technique.

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  Fig. 3. Measurements of the puncture angle between the fine needle and intrahepatic bile duct on the endoscopic ultrasound (EUS) images (A, C), and the puncture angle between the fine needle and echoendoscope (B, D) on the fluoroscopic images. Successful guidewire manipulation cases: The puncture angle was obtuse (110°) on the EUS image (A) and was also obtuse (135°) on the fluoroscopic image (B). Unuccessful guidewire manipulation cases: The puncture angle was acute (55°) on the EUS image (C) and was also obtuse (135°) on the fluoroscopic image (D).

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  Fig. 4. Receiver operating characteristic curves for the evaluation of the impact of the puncture angle between the fine needle and the intrahepatic bile duct and the determination of the optimal cutoff value.

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  Fig. 5. Endoscopic ultrasound and fluoroscopic images of a patient with unsuccessful guidewire manipulation in the B2 puncture group. (A) Abdominal computed tomography reveals swelling of the left lobe. (B) The first puncture angle between the needle and the intrahepatic biliary tract was acute. (C) The guidewire was only inserted into the peripheral bile duct. The scope was not directed toward the hilar side. (D) We re-punctured another bile duct, and the puncture angle between the needle and the intrahepatic biliary tract was obtuse. (E) The guidewire was easily inserted into the hilar bile duct. The scope was toward the peripheral side.

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  Fig. 6. Rescue methods for unsuccessful guidewire manipulation. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy.

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