Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is expected to become
widespread in the future [1]. A 7 Fr dedicated plastic stent (Through and Pass, TYPE‐IT; Gadelius Medical Co.
Ltd., Tokyo, Japan) ([Fig. 1]) is often used to prevent serious adverse events, such as migration or obstruction
of bile duct branches [2]
[3]. However, this stent has a pigtail structure on the stomach side, making it difficult
to place a guidewire through the stent. Furthermore, inserting a guidewire into the
side of the stent is associated with strong frictional resistance and may result in
placement intraperitoneally. When removing the stent with grasping forceps, the tube
may be left in the liver as it is readily fractured ([Fig. 2]). This case demonstrates a method we devised for inserting a guidewire into a dedicated
plastic stent for easy removal.
Fig. 1 The 7 Fr dedicated plastic stent.
Fig. 2 Endoscopic images of stent removal attempt. a The stent is grasped by forceps for removal. b The stent is left behind in the liver following fracture during the removal attempt.
A 75-year-old woman developed cholangitis from perihilar cholangiocarcinoma, which
was not controlled with multiple transpapillary stents. EUS-HGS was performed, and
after creation of the gastrobiliary fistula, the plastic stent was replaced with a
metal stent.
For stent replacement, we inserted the guidewire into a 3.5 Fr catheter (PR-110Q-1;
Olympus Medical Systems, Tokyo, Japan), which was grasped by a snare (SD-8P-1, Olympus)
([Fig. 3]). We used a side-viewing duodenoscope (TJF 260; Olympus) and inserted the cannulated
guidewire on the pigtail side ([Video 1]). After guiding through the loop of the pigtail, the snare was opened, the distal
end of the plastic stent was grasped ([Fig. 4]), and the stent was pulled into the scope for straightening. Then, the guidewire
was inserted into the bile duct and the stent was removed by pulling the snare. A
cholangiogram was performed and the covered metal stent was placed.
Fig. 3 Method for stent removal. a The 3.5 Fr catheter (above) and snare (middle); a disposable electrosurgical snare
(SD-221L-25; Olympus, Tokyo, Japan) can be used as a substitute (below). b The 3.5 Fr catheter grasped by the snare.
Video 1 Easy replacement method for a 7 Fr dedicated plastic stent in endoscopic ultrasound-guided
hepaticogastrostomy.
Fig. 4 The guidewire was inserted into the loop of the pigtail, and the snare grasped the
plastic distal end.
This method enables the guidewire to be reliably placed in the bile duct, enabling
safe exchange of a dedicated plastic stent.
Endoscopy_UCTN_Code_TTT_1AS_2AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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