Troubleshooting guidewire perforation of the bile duct during endoscopic ultrasound-guided hepaticogastrostomy using the liver impaction technique

During endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), manipulation of the guidewire is one of the most challenging steps, and guidewire-related bile duct perforation is a potential adverse event [1] [2]. When a bile duct perforation does occur, there is no established consensus on management, and repeat puncture is frequently required. The liver impaction technique, first described by Ogura et al., involves withdrawing the puncture needle into the liver parenchyma to prevent guidewire kinking or shearing [3]. This maneuver enables redirection of a guidewire that has entered a peripheral bile duct toward the central duct [4]. We report a case of bile duct perforation that was successfully managed using the liver impaction technique.

The patient was a 90-year-old man with obstructive jaundice due to unresectable pancreatic head cancer. Transpapillary biliary drainage was unsuccessful, and EUS-HGS was performed. Using a convex-array echoendoscope, the B3 intrahepatic bile duct (3 mm) was punctured transgastrically with a 19-gauge needle. The bile duct was small and its lumen was easily collapsed during puncture. Cholangiography confirmed entry into the bile duct, and a 0.025-inch angled guidewire was inserted. However, the wire perforated the bile duct and was misplaced outside the bile duct ([Fig. 1]).

Fig. 1 The guidewire perforated the bile duct and was misplaced outside the bile duct during endoscopic ultrasound-guided hepaticogastrostomy.

The puncture needle was then withdrawn into the liver parenchyma. This maneuver restored the collapsed lumen on ultrasound and improved guidewire maneuverability. The guidewire was successfully redirected and advanced into the common bile duct. After catheter insertion, about 30 mL of bile was aspirated. Balloon dilation (3 mm) was performed, followed by placement of a 7-Fr dedicated plastic stent ([Video 1]). The procedure was completed without adverse events, and the patient’s jaundice improved.

Troubleshooting guidewire perforation of the bile duct during endoscopic ultrasound-guided hepaticogastrostomy using the liver impaction technique.Video 1

In small bile ducts, the lumen often collapses during puncture, increasing the risk of guidewire-related perforation. The liver impaction technique improves guidewire maneuverability and maintains duct patency, making it a useful option for managing guidewire perforation during EUS-HGS.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Vila JJ, Pérez-Miranda M, Vazquez-Sequeiros E. et al. Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey. Gastrointest Endosc 2012; 76: 1133-1141
• 2 Miwa H, Sugimori K, Matsuoka Y. et al. Loop technique for guidewire manipulation during endoscopic ultrasound-guided hepaticogastrostomy. JGH Open 2023; 7: 358-364
• 3 Ogura T, Masuda D, Takeuchi T. et al. Liver impaction technique to prevent shearing of the guidewire during endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2015; 47: E583-E584
• 4 Nakamura J, Ogura T, Ueno S. et al. Liver impaction technique improves technical success rate of guidewire insertion during EUS-guided hepaticogastrostomy (with video). Therap Adv Gastroenterol 2023; 16: 17562848231188562

Publication History

Article published online:
07 October 2025