Through-the-mesh technique after endoscopic ultrasonography-guided hepaticogastrostomy: a novel re-intervention method.

ultrasonography-guided hepaticogastrostomy: a novel re-intervention method Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is increasingly used to manage failed endoscopic biliary drainage inpatientswithmalignant biliary obstruction [1–3]. A recent study showed that, for EUS-HGS, a stent ≥3cm in length in the luminal portion may be suitable to prevent stent migration and achieve long-term stent patency [4]. However, suchaplacement can sometimes make re-intervention difficult. Here, we describe a novel re-intervention technique for HGS stent occlusion. A 75-year-old man with advanced pancreatic cancer presentedwith a recurrence of jaundice 11 months after undergoing EUS-HGS using a covered metal stent (Niti-S Biliary Covered Stent; 8×100mm; TaewoongMedical, Seoul, Korea) for distal malignant biliary obstruction (●" Fig.1a). Computed tomography (CT) revealed a dilated intrahepatic and extrahepatic bile duct (●" Fig.1b), and gastroscopy confirmed stent occlusion (●" Fig.2). Re-intervention was attempted via the HGS route; however, insertion of an endoscopic retrograde cholangiopancreatography (ERCP) catheter into the intrahepatic bile duct through the proximal end of the HGS stent failed. Re-intervention through the stent mesh was then attempted. A 0.025-inch stiff guidewire was inserted, penetrating the stent cover membrane close to the gastric puncture site (●" Fig.3). Next, a 6-mm fine-gauge balloon catheter (REN; 3-Fr tip; Kaneka Medix, Osaka, Japan) was inserted into the bile duct, breaking through and opening the stent cover membrane. After successfullyadvancing the guidewire through the distal biliary stricture into the duodenum, an additional metal stent (BileRush selective; 10×60mm, 5.7-Fr delivery system; Piolax, Kanagawa, Japan) was inserted through themesh of the HGS stent to cover the biliary stricture in an antegrade fashion (●" Fig.4;●" Video 1). The postoperative period was uneventful and the patient’s jaundice resolved in a few days. This “through-the-mesh” technique is simple and safe, and could be a useful re-intervention option after EUSHGS.