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Endosc Ultrasound
Endosc Ultrasound
EUSJ
Endoscopic Ultrasound
2303-9027
2226-7190
Lippincott Williams & Wilkins

EUSJ_240075
10.1097/eus.0000000000000073
00011
3
Images and Videos
Technique tips for fitting alignment of puncture route during EUS-guided hepaticogastrostomy (with video)
Ogura Takeshi 1 2 ∗
Bessho Kimi k.bessy0730@gmail.com
2
Hattori Nobihiro nobuhero.222@gmail.com
2
Uba Yuki omcuba.0114@gmail.com
2
Nishikawa Hiroki nishikawa_6392_0207@yahoo.co.jp
2
1 Endoscopy Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
2 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan.
∗ Address for correspondence: Endoscopy Center, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka 569-8686, Japan. E-mail: oguratakeshi0411@yahoo.co.jp (T. Ogura).
Jul-Aug 2024
26 8 2024
13 4 276277
21 1 2024
27 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc on behalf of Scholar Media Publishing.
2024
Wolters Kluwer on behalf of Scholar Media Publishing.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

OPEN-ACCESSTRUE
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pmcTechnical tips for EUS-guided hepaticogastrostomy (EUS-HGS) can be divided into 4 steps: intrahepatic bile duct (IHBD) puncture, guidewire insertion, tract dilation, and stent deployment.[1] Various devices and tips for guidewire insertion, dilation devices, or dedicated stents have been reported.[2–5] Although IHBD puncture is the first step of EUS-HGS, the technical details have not been reported. During IHBD puncture, misalignment between the needle and the IHBD may be one reason for failed IHBD puncture. The technique to align the axis of the needle with that of the IHBD is described in this case report.

A 46-year-old man was admitted to our hospital due to obstructive jaundice. Computed tomography showed a pancreatic tumor with IHBD dilatation. EUS-FNA was performed, and adenocarcinoma was diagnosed. Biliary drainage under endoscopic retrograde cholangiopancreatography guidance was attempted, but duodenoscope insertion failed due to duodenal obstruction. Therefore, EUS-guided antegrade stenting combined with HGS was attempted. First, IHBD puncture was performed using a 19-gauge needle [Figure 1A]. However, bile juice could not be aspirated because the axes of the needle and the IHBD were misaligned. To align the axes, the needle was pulled back within hepatic parenchyma [Figure 1B], and then the echoendoscope was gently pulled back [Figure 2A]. By doing so, the needle’s axis could be adjusted, and then IHBD puncture was successfully performed [Figure 2B]. Bile juice aspiration was also successfully performed. A 0.025-inch guidewire was then inserted. After the endoscopic retrograde cholangiopancreatography catheter was inserted, lower common bile duct obstruction was observed. An uncovered self-expandable metal stent was then placed for antegrade stenting. Finally, EUS-HGS using partially covered self-expandable metal stent deployment was performed without any adverse events [Video 1].

Figure 1 A, Intrahepatic bile duct puncture is performed, but bile juice cannot be aspirated. B, To adjust the axes of the needle and the intrahepatic bile duct, the needle is pulled back within the hepatic parenchyma.

Figure 2 A, The echoendoscope is pulled back. B, Intrahepatic bile duct puncture is successful.

In conclusion, the present technique may be helpful for failed IHBD puncture, although further evaluation is needed.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Conflicts of Interest

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Author Contributions

Takeshi Ogura wrote the paper. Kimi Bessho, Nobuhiro Hattori, Yuki Uba, and Hiroki Nishikawa performed data interpretation, revised the work critically for important intellectual content, gave final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Published online: 26 August 2024
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References

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