Mechanism of Fibrotic Anastomosis Formation in Endoscopic Ultrasound-guided Hepaticogastrostomy Using a Plastic Stent: Insights From an Autopsy Case of Perihilar Cholangiocarcinoma.
This study provides evidence of significant fibrotic changes at the site of EUS-HGS using a plastic stent, suggesting that structural stabilization can occur even without sustained radial force.
Where it sits
this study against the rest of the bpc-157 corpusSummary and findings
This paper evaluates the histopathological changes in an endosonographically created route (ESCR) following endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using a plastic stent in an 83-year-old man with perihilar cholangiocarcinoma. The patient underwent the procedure for recurrent biliary obstruction and died 141 days later, after which an autopsy was performed. The study reports on the fibrotic changes observed at the ESCR site.
Abstract
Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an established alternative to other biliary drainage techniques for treating malignant biliary obstruction. Although the anastomosis created by EUS-HGS is believed to mature within several weeks, histopathological evidence supporting this assumption remains limited, particularly in procedures using plastic stents. Here, we report a case of perihilar cholangiocarcinoma in which an endosonographically created route (ESCR) formed by EUS-HGS using a plastic stent was histologically evaluated at autopsy. An 83-year-old man underwent EUS-HGS with a 7-Fr plastic stent for recurrent biliary obstruction after duodenal stenosis, which made endoscopic retrograde cholangiography infeasible. The patient died of disease progression 141 days after the initial EUS-HGS, and an autopsy was performed. Macroscopic evaluation revealed adhesions between the liver and stomach at the ESCR site. Masson's trichrome staining revealed a well-defined concentric fibrotic tunnel surrounding the stent tract, with fibrotic thickness comparable to the stent diameter. Fibrotic changes varied across tissue layers, being minimal at the mucosal penetration site and most pronounced at the subserosal and serosal levels. Previous reports of EUS-guided biliary drainage with self-expandable metallic stents suggest that radial force contributes to anastomosis maturation. In contrast, the present case demonstrates that a robust fibrotic ESCR can develop even after EUS-HGS with a plastic stent lacking sustained radial force. These findings provide pathological evidence for structural stabilization of ESCR and support the structural basis for trans-ESCR procedures.
Background
This paper addresses the histopathological evidence of anastomosis maturation following EUS-HGS, a technique used for malignant biliary obstruction. Prior knowledge indicates that anastomoses are believed to mature over several weeks, but histological confirmation, particularly with plastic stents, is limited. This study is significant as it provides pathological insights into the fibrotic changes associated with EUS-HGS.
Methods
The study reports a case of an 83-year-old man who underwent EUS-HGS with a 7-Fr plastic stent. The autopsy was performed 141 days post-procedure to evaluate the histopathological changes at the ESCR site. Primary outcome measures included macroscopic and microscopic evaluations of the fibrotic changes.
Results
Macroscopic evaluation revealed adhesions between the liver and stomach at the ESCR site. Masson's trichrome staining indicated a well-defined concentric fibrotic tunnel surrounding the stent tract, with fibrotic thickness comparable to the stent diameter. Fibrotic changes varied, being minimal at the mucosal penetration site and most pronounced at the subserosal and serosal levels.
Interpretation
The findings suggest that robust fibrotic changes can develop even in the absence of sustained radial force, contrasting with previous reports on self-expandable metallic stents. While the study provides valuable insights, the effect size of the fibrotic changes and their clinical implications remain unclear due to the single-case nature of the study. This limits the ability to generalize the results to broader clinical practice.
Key findings
- 141 days post-EUS-HGS, the patient died of disease progression.
- Macroscopic evaluation revealed adhesions between the liver and stomach at the ESCR site.
- Masson's trichrome staining showed a well-defined concentric fibrotic tunnel surrounding the stent tract.
- Fibrotic thickness was comparable to the stent diameter.
- Fibrotic changes were minimal at the mucosal penetration site and most pronounced at the subserosal and serosal levels.
Limitations
- single case study limits generalizability
- patient's disease progression may confound results
- no control group for comparison
- short follow-up period for assessing long-term outcomes