LAUSR

A68-YEAR-OLD WOMAN with distal biliary stricture due to unresectable pancreatic cancer underwent endoscopic ultrasonography (EUS)-guided hepaticogastrostomy (EUS-HGS) because endoscopic transpapillary biliary drainage was unsuccessful due to a gastric outlet obstruction. Puncture of the intrahepatic bile duct (B3) was performed via the stomach using a 19G needle (EZ Shot 3 Plus; Olympus Co., Tokyo, Japan) under EUS guidance. A 0.025-inch guidewire (Fielder25; Asahi Intecc Co., Aichi, Japan) was inserted into the bile duct after confirming the location of the bile duct by using cholangiography. Then the puncture tract was dilated using a novel 7F spiral dilator (Tornus ES; Olympus Co.), the tip of which has a screw shape (Fig. 1, Video S1). When the assistant turned the handle of the spiral dilator clockwise, its tip advanced while dilating the puncture tract smoothly. The operator did not have to push the dilator while dilating, and therefore, the scope remained stable (Video S1). After dilation of the tract, the dilator was withdrawn by the assistant by turning the dilator counterclockwise. In addition, the distal biliary stricture was dilated with this novel dilator. It could be advanced through the curve in the intrahepatic bile duct without resistance, meaning the stricture could be dilated easily. Finally, a metallic stent was placed at the stricture, and a plastic stent was placed at the puncture site (Fig. 2). No complications, such as bleeding or peritonitis, were observed after the procedure.