Cholangioscopy and double guidewires facilitate a difficult endoscopic ultrasound-guided gastroenterostomy

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with electrocautery-enhanced lumen-apposing metal stents (LAMSs) is a promising minimally invasive approach for benign or malignant gastric outlet obstruction (GOO). Guidewire-assisted oroenteric catheters (OECs) or balloon catheters are commonly used to distend the small bowel for puncture. However, failed guidewire passage may complicate the procedure.

A 59-year-old woman with GOO after liver transplantation and hilar bile duct plasty was scheduled for EUS-GE. However, multiple endoscopes (ultra-slim endoscope, enteroscope, gastroscope, and colonoscope) failed to reach the pylorus due to severe scope looping, despite abdominal compression and repositioning ([Fig. 1] a). To overcome this situation, a 9 Fr cholangioscope (IMAX, Nanwei Medical) was advanced through the 3.7 mm channel of a colonoscope, traversed the pylorus, and entered the duodenal bulb ([Fig. 1] b). The pathway was visualized hidden at a 1 o’clock position in the duodenal bulb ([Fig. 2]). Under direct vision, an angled-tip hydrophilic guidewire (RF*PA35263M, Terumo) was advanced, followed by the cholangioscope into the jejunum ([Fig. 3]). Subsequently, a Boston Scientific Jagwire high-performance guidewire (M00556580) was inserted via an 8.5 Fr bougie catheter to secure dual-wire access ([Fig. 4]). Then, a 7 Fr OEC was used to infuse dye-mixed saline. Finally, a 15-mm Hot AXIOS LAMS (Boston Scientific) was successfully deployed under a linear echoendoscope guidance, with positioning confirmed by endoscopy, EUS, and fluoroscopy ([Fig. 5], [Video 1]). The second guidewire was then withdrawn. The patient resumed a liquid diet 3 days later.

Fig. 1 a Schematic illustration showing severe scope looping in a patient with gastric outlet obstruction and surgically altered anatomy after liver transplantation and hilar bile duct plasty, preventing endoscopic passage to the pylorus despite abdominal compression and repositioning. b Schematic illustration of a cholangioscope advanced through the working channel of a colonoscope to traverse the pylorus and enter the duodenal bulb, overcoming the limitation of severe scope looping in surgically altered anatomy.

Fig. 2 The hidden pathway to the jejunum located at the 1 o’clock position in the duodenal bulb, obscured by altered gastric anatomy.

Fig. 3 An angled-tip hydrophilic guidewire was inserted, navigating a sharply curved duodenal bulb with the maximal bend highlighted by a red circle, and advancing distally into the jejunum.

Fig. 4 A fluoroscopic image showing dual-guidewire access established using an 8.5 Fr bougie catheter.

Fig. 5 Successful deployment of a LAMS between the stomach and the jejunum under combined guidance of dual-guidewire access and cholangioscopy, with the LAMS position highlighted by a red circle. LAMS, lumen-apposing metal stent.

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Cholangioscopy-assisted EUS-GE in a patient with surgically altered anatomy. The video highlights overcoming severe scope looping by cholangioscopy through a colonoscope, precise navigation using angled-tip guidewires under direct vision, establishment of dual-guidewire access for the procedural backup, and safe deployment of a LAMS with real-time confirmation, minimizing fluoroscopy use.Video 1

This case highlights key technical advantages that enabled successful EUS-GE in surgically altered anatomy. First, cholangioscopy within a colonoscope increased rigidity and reach, overcoming severe gastric looping. Second, angled-tip guidewires enabled precise navigation under direct vision by cholangioscopy. Third, real-time visualization allowed the confident identification of the jejunal lumen without contrast or radiation. Finally, dual-guidewire access offered a backup for feeding tube placement and enabled repeat cholangioscopy to confirm LAMS deployment, reducing reliance on fluoroscopy.

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Contributorsʼ Statement

Jiahuan Liu: Data curation, Formal analysis, Writing – original draft. Shuai Bai: Conceptualization, Investigation, Writing – original draft. Jia Xie: Investigation, Visualization. Jinlin Yang: Conceptualization, Methodology, Writing – review & editing. Rui Wang: Conceptualization, Funding acquisition, Project administration, Resources, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

Publication History

Article published online:
08 January 2026