LAUSR

A 57‐YEAR‐OLD MALE with Roux-en-Y hepaticojejunostomy (HJ) stricture with separation of intrahepatic ducts (IHDs) received percutaneous transhepatic drainage (PTBD) insertion. The right IHD dilation by enteroscopy, percutaneous cholangioscopy or magnet placement were unsuccessful. Endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS) was performed after diluted contrast injection into the right PTBD. The 19-G EUS fine needle aspiration needle was used but unable to achieve good puncture position and was changed to the 22G needle followed by 0.018-inch coated stiff guidewire (Novagold, Boston, MA, USA) insertion. The 6-Fr coaxial cautery dilator (Cystotome; EndoFlex, Voerde, Germany) could not pass through the dense fibrotic tissue surrounding the liver hilum. The percutaneous choledochoscope was inserted and the 0.018-inch guidewire was retracted through the skin. Using the firm wire tension between the percutaneous side and the EUS side, coaxial cautery was able to be inserted through the tract. The wire was then exchanged to the 0.035-inch guidewire and a 10 9 80 mm fully covered self expandable metal stent (FCSEMS) was placed. Four weeks later, the FCSEMS was replaced by multiple plastic stents to prevent stent migration and minimized side branch obstruction and the PTBD was removed (Fig. 1, Video S1). EUS-HDS has been used for the treatment of isolated right intrahepatic bile duct obstruction. In cases with small bile duct or with difficult position, EUS-guided intervention Figure 1 (a) Right intrahepatic bile duct cholangiogram showed right intrahepatic bile duct obstruction. (b) Endoscopic ultrasound (EUS)-guided right intrahepatic bile duct puncture using 22-G needle was performed followed by 0.018-inch guidewire insertion. (c) Percutaneous choledochoscope was inserted and the 0.018-inch guidewire was retracted through the skin. (d) With the aid of percutaneous wire traction, the fully covered metal stent could be placed across the fistula.