LAUSR

A 56-year-old man was admitted to our hospital with obstructive jaundice caused by extrahepatic cholangiocarcinoma that developed from a congenital choledochal cyst (▶Fig. 1). Endoscopic retrograde cholangiopancreatography was hampered by ampullary effacement caused by malignant invasion. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy was therefore attempted using an 8-cm fully covered self-expandable metal stent (FCSEMS) (Boston Scientific, Marlborough, Massachusetts, USA). A linear echoendoscope was advanced to the stomach. The intrahepatic bile duct (B3) was punctured with a 19G aspiration needle (▶Fig. 2). A 0.035-inch guidewire was subsequently inserted via the aspiration needle. Following release of the FCSEMS, cholangiography revealed maldeployment of the proximal flange of the stent into the abdominal cavity. We then switched the echoendoscope to a gastroscope (▶Fig. 3). The entire thickness of the gastric wall was incised using a DualKnife in the puncture location. The gastroscope was further inserted into the abdominal cavity to visualize the position of the FCSEMS. Repositioning of the FCSEMS was achieved by using a foreignbody forceps to pull out the proximal flange through the incision in the gastric wall. Finally, the defect in the gastric wall was sutured with endoclips (▶Video 1). Cholangiography confirmed that the FCSEMS was in place. The post-procedure period was uneventful and the bilirubin level was improved. Stent maldeployment during EUS-guided hepaticogastrostomy is a significant adverse event that needs to be immediately managed [1]. The rescue approach described here, which employs transgastric natural orifice transluminal endoscopic surgery (NOTES), avoids the need for emergency surgery, as well as sacrifice of the stent, hence saving on cost.