LAUSR

BALLOON ENTEROSCOPY-ASSISTED ENDOSCOPIC retrograde cholangiopancreatography (BEERCP) has become the first-line therapy for biliopancreatic anastomotic strictures in patients with surgically altered anatomy (SAA). However, BE-ERCP is difficult in patients with SAA who have complete obstruction of the anastomosis. On the other hand, endoscopic ultrasound (EUS)-guided transanastomotic drainage using a forward-viewing echoendoscope (FV-EUS) has been reported to be useful in these patients. Recently, the usefulness of a novel spiral dilator in cases of severe stricture has also been reported. Here, we describe biliary drainage using an FV-EUS and this novel dilator. A 79-year-old woman who had undergone pancreaticoduodenectomy for intraductal papillary mucinous carcinoma was admitted to another hospital for anastomotic stricture. Percutaneous transhepatic biliary drainage was attempted, but contrast medium could not flow through the anastomosis, indicating complete obstruction. Therefore, the patient was referred to our hospital. BE-ERCP was attempted first, but canalization was unsuccessful (Fig. 1). Next, EUSguided choledochojejunostomy using FV-EUS was performed. First, we inserted the FV-EUS into the anastomosis site. Then, after detecting the dilated bile duct, we punctured it with a 19G needle (EZshot3 plus; Olympus Medical Systems, Tokyo, Japan) and placed the 0.025 inch guidewire into the bile duct. Next, a 7Fr mechanical dilator (ES dilator; Zeon Medical, Tokyo, Japan) was inserted to dilate the puncture tract but could not pass through the anastomosis due to severe stricture. Therefore, we used the novel 7Fr spiral dilator (Tornus ES; Olympus Medical Systems). The spiral dilator was inserted smoothly, and the puncture tract