LAUSR

A 57-year-old man with metastatic periampullary carcinoma and a history of previous endoscopic retrograde cholangiopancreatography (ERCP) and placement of a double-pigtail plastic stent for distal common bile duct (CBD) obstruction presented with severe cholangitis and blockage of the stent. Emergency left-sided percutaneous transhepatic biliary drainage (PTBD) was performed. A computed tomography scan prior to the PTBD showed gastric outlet obstruction with a distally migrated double-pigtail stent, hinged in the distal CBD (▶Fig. 1). During removal of the plastic stent, an infiltrative narrowing was seen, which started at the junction of the first and second parts of the duodenum, and extended to the papilla (▶Fig. 2 a). A pediatric upper gastrointestinal endoscope (GIF XP170N; Olympus Medical Systems, Tokyo, Japan) was negotiated across the narrowing; however, the stent could not be retrieved. Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) and subsequent retrieval of the stent through the afferent limb of the gastrojejunostomy was therefore planned (▶Video 1). An oroenteric catheter was placed across the narrowing into the proximal jejunum. The EUS-GJ was created using the free-hand technique with a 20×10-mm Hot-Axios lumen-apposing metal stent (LAMS) delivery system (Boston Scientific, Marlborough, Massachusetts, USA), by puncturing the jejunum after it had been distended with saline andmethylene blue. On the third day after the EUS-GJ, an upper gastrointestinal endoscope was passed across into the afferent limb of gastrojejunostomy. The plastic stent (▶Fig. 2b) was grasped using a rat-tooth forceps and removed with gentle traction to avoid displacing the gastrojejunostomy stent (▶Fig. 3 a). After successful retrieval of the plastic stent, the PTBD catheter was internalized and a 10×80-mm selfexpanding metal stent (Niti-S; Taewoong Medical, Seoul, South Korea) was placed in the CBD (▶Fig. 3b). E-Videos