LAUSR

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is performed to create a biliary drainage route for malignant distal biliary obstruction during complicated endoscopic retrograde cholangiopancreatography [1, 2]. However, when EUS-HGS is performed in patients with cholangitis and ascites, metal stent placement may cause peripheral obstructive cholangitis (▶Fig. 1 a), while plastic stentsmay cause biliary peritonitis due to bile leakage into the ascites (▶Fig. 1b) [3, 4]. To address this challenge, we implemented a novel EUS-HGS method of hepatic parenchymal metal stent placement with plastic stent in the bile duct (▶Fig. 2), which proved to be effective (▶Video 1). Our patient was a 64-year-old woman with biliary and duodenal stents for relieving the obstruction of the distal bile duct and duodenum due to unresectable pancreatic cancer. She developed cholangitis due to biliary stent dysfunction (▶Fig. 3). We decided to perform EUSHGS with hepatic parenchymal metal stent placement using a laser cut-type fully covered metal stent (LFCMS) along with plastic stent placement in the bile duct. After puncturing B3 with a 19-gauge needle using a convex ultrasound endoscope, a 0.025-inch guidewire was placed into the common bile duct, and a 6-mm balloon was used to dilate the fistula. Subsequently, the LFCMS (8mm diameter, 8 cm length, X-Suit NIR Biliary Metallic Stent; Olympus Medical Systems, Tokyo, Japan) was deployed, with the stent end in the hepatic parenchyma slightly outside the bile duct, while being careful not to occlude the bile duct with the stent. After confirming the position of themetal stent by contrast to ensure that it was not in the bile duct, a 7-Fr plastic stent (TYPE IT; E-Videos