LAUSR

Recently, endoscopic ultrasound-guided hepaticogastrostomy (EUSHGS) has been increasingly used for biliary drainage in patients with surgically altered anatomy and duodenal obstruction. Covered selfexpandable metal stent (CSEMS) migration into the abdominal cavity is a severe complication of EUS-HGS and requires surgical intervention. Previously reported prevention measures include using CSEMS with an antimigratory single flange and using crisscross-anchor 5-Fr plastic stents with 10 mm CSEMS. Currently, 6 mm CSEMS are frequently used in patients without hepatic duct dilatation, and no antimigration measure has been developed. Herein, we report a case in which the scarecrow method, using a 4-Fr plastic stent, effectively prevented CSEMS migration. A 67-year-old woman, previously diagnosed with gallbladder adenocarcinoma who had undergone transpapillary biliary drainage, presented with obstructive jaundice due to stent obstruction. EUS-HGS was required because of duodenal obstruction. Following drainage of the massive ascites (Fig. 1a), EUS-HGS was performed using a CSEMS (Niti-S Biliary S-type Stent; Taewoong Medical, Gyeonggi-do, South Korea, 120 mm 9 6 mm) for segment 3 (Fig. 1b,c). Three days after the procedure, the CSEMS had mostly migrated into the abdominal cavity (Fig. 1d), and endoscopy revealed approximately 2 cm of the CSEMS remaining in the stomach (Fig. 2a). The CSEMS was moved 3 cm into the stomach by grasping its distal end with biopsy forceps (Fig. 2b). To prevent further CSEMS migration, a 4-Fr plastic stent (Gadelius Medical Co., Ltd., Tokyo, Japan, 7 cm) was inserted in its distal end over a 0.025inch guidewire (Fig. 2c,d). The patient was discharged 4 days after the procedure without any adverse events including CSEMS migration. Patients with massive ascites are especially at risk for CSEMS migration after EUS-HGS. Additional skillful procedures based on careful follow-up are essential to avoid complete migration, and the scarecrow method using a 4-Fr plastic stent can be useful in such patients.