Endoscopic ultrasonography-guided antegrade stenting combined with hepatico- gastrostomy/hepaticojejunostomy using ultraslim instruments

Techniques for endoscopic ultrasonography (EUS)-guided biliary drainage (EUSBD) have been developed, and EUS-guided antegrade stenting (EUS-AGS) and EUS-guided hepaticogastrostomy (EUSHGS)/hepaticojejunostomy (HJS) are suitable for gastric outlet obstruction (GOO) or surgically altered anatomy. EUS-AGS alone carries the potential risk of causing bile leakage from a fistula; however, EUS-AGS in combination with EUS-HGS or EUS-HJS appears safer, as it can reduce the risk of a bile leak [1, 2]. We present two patients who underwent EUS-HGS or EUS-HJS combined with EUSAGS using ultraslim instruments. Patient #1 was a 62-year-old woman who had undergone a previous total gastrectomy for gastric cancer and later developed obstructive jaundice. First, a B3 branch was punctured using a 19G needle via a transjejunal approach, and a 0.025-inch guidewire (VisiGlide 2; Olympus, Tokyo, Japan) (▶Fig. 1) was placed. Next, a tapered endoscopic retrograde cholangiopancreatography (ERCP) catheter (01 20 21 1; MTW Endoskopie, Düsseldorf, Germany) (▶Fig. 2) was used to dilate the fistula, following successful passage of the guidewire through the stricture. EUS-AGS was then performed using a novel ultraslim uncovered self-expandable metal stent (SEMS; BileRush Selective; 5.7 Fr, 10-mm diameter; Piolax Medical Devices, Kanagawa, Japan) (▶Fig. 2). Finally, a novel 7-Fr plastic stent (TYPE-IT stent; Gadelius Medical Co. Ltd., Tokyo, Japan) [3] (▶Fig. 3) was placed to create an EUS-HJS (▶Fig. 4; ▶Video1). Patient #2 was a 68-year-old man with GOO caused by gastric cancer who developed obstructive jaundice. EUS-AGS and EUS-HGS were performed as described