Eus-guided transduodenal drainage of a giant perihilar hepatic cyst causing biliary obstruction using a lumen apposing metal stent

Background Hepatic cysts are typically benign and asymptomatic, but giant cysts may cause clinically significant mass effect, including biliary obstruction. Standard treatment includes percutaneous aspiration or surgical fenestration. Endoscopic ultrasound (EUS)-guided drainage with lumen-apposing metal stents (LAMS) offers a minimally invasive approach for selected patients. We present an 84-year-old man with a giant perihilar hepatic cyst seen on computed tomography imaging which caused biliary obstruction, jaundice, and emesis (Figure 1). Methods EUS demonstrated a 10 × 7 cm cyst in close apposition to the duodenal bulb, with only 5 mm between the cyst and duodenal wall (Video 2). A 15 × 10 mm cautery-enhanced LAMS was deployed transduodenal, followed by placement of a coaxial 7 Fr × 3 cm double-pigtail stent (Videos 2-5). Results The cyst was successfully drained with immediate decompression and rapid improvement in hyperbilirubinemia. Follow-up CT demonstrated marked cyst reduction to 1.8 × 1.5 cm with resolution of biliary dilation. Given the rapid improvement, the LAMS was subsequently removed at 5 weeks without adverse event, and the patient remained asymptomatic with normalized liver biochemistries at 8 month follow up. Conclusion Transduodenal EUS-guided LAMS drainage provided effective internal decompression of a giant perihilar hepatic cyst causing biliary obstruction in a high-risk patient. This approach may offer a minimally invasive alternative to percutaneous or surgical management when a favorable cyst-enteric window is present.