LAUSR

A 55-year-old-female suffered from advanced obstructive jaundice due to resecetable pancreatic cancer (▶Fig. 1). Preoperative biliary drainage via endoscopic retrograde cholangiopancreatography (ERCP) was attempted but unsuccessful due to duodenal obstruction. We then attempted endoscopic ultrasoundguided antegrade stenting using a novel uncovered self-expandable metal stent (SEMS) with an ultra-slim 5.4-Fr introducer and an ultra-tapered stiff tip (YABUSAME; Kaneka Medix, Osaka, Japan) (▶Fig. 2) after placement of a duodenal stent (▶Video 1). B2 was punctured with a 19-gauge needle via the stomach followed by contrast injection to depict the biliary tree (▶Fig. 3 a). Then, a 0.025inch angle-tip guidewire (INAZUMA; Kaneka Medix) was successfully manipulated antegrade into the duodenum through the stricture. Just after a removal of the needle, an introducer of a YABUSAME (10×60mm) was inserted into the bile duct without any tract dilation and easily passed through the stricture (▶Fig. 3b). Finally, the stent was deployed (▶Fig. 3 c). No adverse events had occurred for two weeks until surgery. EUS-guided biliary drainage includes bilioenterostomy, the rendezvous technique, and antegrade stenting. In preoperative biliary drainage, endoscopic ultrasound-guided bilioenterostomy seems unfavorable because the influence of a bilioenteric fistula on surgery is unknown [1]. Although the EUS-guided rendezvous technique and antegrade stenting do not form a fistula, both have pros and cons. In the rendezvous technique, tract dilation is usually unnecessary, but complicated steps including scope exchange, grabbing and pulling the guidewire, and cannulation are required. EUS-guided antegrade stenting is a simpler method; however, tract dilation with a dilator [2] or catheter [3] prior to insertion of a SEMS introducer is usually required and that increases a risk of the bile leak. In antegrade stenting, this novel introducer is likely to allow a SEMS to be placed just after needle removal and the bile leak and procedural time to be decreased. This method could be a useful alternative after failed ERCP in preoperative biliary drainage.