LAUSR

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is the standard endoscopic procedure for biliary obstructions [1–2]. Although various complications such as migration, perforation, and abdominal peritonitis have been reported after EUS-HGS [3–5], the reinterventionmethod for them has not been established. Herein, we present a case of successful reintervention for a migrated stent after EUS-HGS using a dual-channel endoscope and grasping forceps. An 88-year-old man with pancreatic cancer underwent EUS-HGS for malignant biliary obstruction, and a partially covered self-expandable metallic stent (SEMS) was placed on the B3 branch. The patient had a high fever 2 days after EUS-HGS. Computed tomography (CT) revealed free air in the abdominal cavity (▶Fig. 1), which was caused by the shifting of the uncovered part of the SEMS to the gastric side by respiratory fluctuation. A reintervention for additional stent placement was urgently performed. A dual-channel endoscope (GIF-2TQ260M; Olympus, Tokyo, Japan) was inserted into the EUS-HGS site. A guidewire was then advanced through the EUS-HGS stent into the right hepatic duct (▶Video 1). However, the catheter could not advance through the B3 branch due to its strong bend. The EUS-HGS stent was too long, poorly anchored, and was difficult to align with the axis; therefore, it could not transmit force in the direction of the catheter (▶Fig. 2). Grasping forceps inserted from the other channel grasped and pulled the stent (▶Fig. 3), after which the catheter and stent delivery system advanced through the bend of the B3 branch by counter-traction (▶Fig. 4). The fully covered SEMS (Boston Scientific, Marlborough, Massachusetts, USA) was then deployed through the stent to the proximal B3 branch (▶Fig. 5). After 1 week, CT showed the disappearance of free air and the biliary metallic stent in the appropriate position. Stent placement using a dual-channel endoscope and grasping forceps may be considered a useful treatment for stent complications after EUS-HGS.