Simultaneous bridging and antegrade stent-in-stent placement via endoscopic ultrasound-guided hepaticogastrostomy using novel multi-hole metal stents

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been used in combination with bridging and antegrade stenting [1] [2]; however, uncovered metal stents often suffer from tumor ingrowth and limited patency [3]. A newly developed multi-hole metal stent with a 5.9-Fr slim delivery system (HANAROSTENT Biliary Multi Hole Benefit; M.I. Tech Co., Ltd, Pyeongtaek, South Korea) has been developed ([Fig. 1] [4] [5]). Herein, we report a novel EUS-HGS technique achieving simultaneous bridging and antegrade stent-in-stent placement using multi-hole metal stents ([Video 1]). A 67-year-old woman was referred to our hospital with hilar biliary obstruction due to advanced gallbladder cancer ([Fig. 2]). Because the duodenum was obstructed, EUS-HGS was selected as the initial drainage approach ([Fig. 3], [Fig. 4]). The intrahepatic bile duct was punctured using a 19-gauge needle, and after contrast injection, a 0.025-inch guidewire was advanced across the stricture into the common bile duct, followed by insertion of a double-lumen catheter. Cholangiography revealed a bismuth type IIIa stricture, and a second guidewire was inserted into the right anterior branch. A slim delivery system for the multi-hole metal stent was smoothly advanced across the hilar stricture into the anterior brunch. The first multi-hole metal stent (6 mm and 6 cm) was deployed as a bridging stent from the right to the left intrahepatic bile duct. The guidewire was then manipulated through a side hole of the first stent toward the common bile duct, and both the side hole and the stricture were dilated using a balloon catheter. A second multi-hole metal stent was inserted as an antegrade stent through the side hole, resulting in successful partial stent-in-stent placement. Finally, a plastic stent was placed through the hepaticogastrostomy tract. To the best of our knowledge, this is the first report of EUS-HGS with simultaneous bridging and antegrade stent-in-stent placement using multi-hole metal stents. This technique may offer prolonged patency for hilar biliary obstruction with duodenal stenosis.

Fig. 1 HANAROSTENT Biliary Multi Hole Benefit (M.I. Tech Co., Ltd, Pyeongtaek, South Korea). The 5.9-Fr slim delivery system can pass smoothly through the side hole.

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A novel EUS-HGS technique achieving simultaneous bridging and antegrade stent-in-stent placement using multi-hole metal stents. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy.Video 1

Fig. 2 Computed tomographic images before biliary drainage. a Coronal imaging shows a bismuth type IIIa hilar biliary obstruction caused by advanced gallbladder cancer. b The duodenum is obstructed by tumor invasion.

Fig. 3 Endoscopic ultrasonography-guided hepaticogastrostomy. a The intrahepatic bile duct is punctured using a 19-gauge needle. b A guidewire is advanced across the stricture, and cholangiography confirms hilar biliary obstruction. c A second guidewire is inserted into the right anterior branch using a double-lumen catheter. d The slim delivery system of the first stent is smoothly advanced into the right anterior branch.

Fig. 4 Bridging and antegrade stent-in-stent placement under EUS-HGS guidance. a After deployment of the first multi-hole metal stent as a bridging stenting, the guidewire is manipulated through a side hole toward the common bile duct. b The guidewire is advanced across the stricture, followed by 6-mm balloon dilation of both the side hole and the stricture. c The second multi-hole metal stent is deployed as an antegrade stent through the side hole of the first stent. d A 7-Fr plastic stent is finally placed through the hepaticogastrostomy tract. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy.

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Contributorsʼ Statement

Haruo Miwa: Writing – original draft, Writing – review & editing. Hiromi Tsuchiya: Writing – review & editing. Shotaro Tsunoda: Writing – review & editing. Kazuki Endo: Writing – review & editing. Ritsuko Oishi: Writing – review & editing. Yuichi Suzuki: Writing -–review & editing. Shin Maeda: Supervision, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

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Publication History

Article published online:
22 January 2026