LAUSR

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HPG) is still unfairly confined to palliation of advanced malignancies. However, this technique might be of significant help in benign indications, providing effective and safe longterm access to the biliary tree and facilitating the definitive treatment of biliary diseases [1–4]. A 65-year-old patient with a history of pancreaticoduodenectomy was referred for a biliary leak following a recent redo hepaticojejunostomy (▶Fig. 1). Enteroscopy-directed endoscopic retrograde cholangiopancreatography (ERCP) was performed, with confirmation of the biliary leak and insertion of a 7-Fr doublepigtail stent. Unfortunately, this stent migrated distally. With the left-sided bile duct dilation and surgically altered anatomy in mind, EUS-guided antegrade stenting was attempted. The left main hepatic duct was accessed using a 19G needle (▶Fig. 2); the guidewire was advanced into the small bowel, after which the trajectory was consolidated using a 6-Fr cystotome, and a fully covered self-expandable metal stent (FCSEMS) was placed. However, this stent migrated into the small bowel, and therefore an EUS-guided HPG was performed over the same guidewire (▶Fig. 3) in an effort to provide immediate biliary drainage together with long-term access (▶Video 1). Considering the benign indication, an FCSEMS (10×80mm) was used for EUSguided HPG. A revision was performed 2 weeks later, with extraction of the FCSEMS and replacement with a doublepigtail stent (10 Fr ×10 cm), bridging the fistula (▶Fig. 4). A new revision was performed 3 months later that showed complete resolution of the biliary leak (▶Fig. 5), after which two double pigtails were inserted in similar fashion, to be finally extracted in 3 months’ time. Our case illustrates that in patients with benign indications and impossible/failed retrograde access, EUS-guided HPG may ensure an effective long-term gateway to definitive endoscopic treatment of biliE-Videos