Endoscopic ultrasound-guided hepaticogastrostomy using a novel double-lumen tapered dilator combined with a 22-G needle

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) can be indicated for failed endoscopic retrograde cholangiopancreatography (ERCP). Recently, various transendoscopic ultrasonography/endosonography-created route procedures have been developed, such as antegrade bile duct stone removal and stricture management [1]. These procedures may be mainly indicated for benign biliary disease. Compared with malignant biliary disease, EUS-HGS might be challenging in cases of benign biliary disease because the intrahepatic bile duct is not very dilated. Indeed, compared with a meta-analysis of EUS-HGS for malignant biliary disease [2], the technical success rate might be lower for benign biliary disease [3]. A 22 G needle may improve the technical success of bile duct puncturing. However, because a 0.018-inch guidewire, which has little stiffness, should be used, device insertion into the biliary tract may be challenging. To overcome this, a novel dilation device (Meissa; Japan Lifeline, Tokyo, Japan) has been developed ([Fig. 1]). This device has a 2.3-Fr tip and a maximum diameter of 7.4 Fr. In addition, a 2-cm side hole is provided from the tip. Contrast medium injection, aspiration of bile juice, and 0.025-inch guidewire insertion can be performed. Therefore, if this device is used, the double-guidewire technique can be performed without additional device exchange with a 0.018-inch guidewire. A challenging case of EUS-HGS due to a non-dilated bile duct is described.

Fig. 1 A novel double lumen dilation device.

An 80-year-old man was referred to our hospital due to acute cholangitis caused by a common bile duct stone. He underwent distal gastrectomy with a Roux-en-Y anastomosis. Stone removal was then performed through an enteroscopic approach in another hospital but failed. Therefore, EUS-HGS was attempted. Since the diameter of the intrahepatic bile duct was only 1 mm ([Fig. 2], arrow), a 22 G needle was selected as the puncture needle. The intrahepatic bile duct was successfully punctured and contrast medium was also injected. Then, a 0.018-inch guidewire was inserted ([Fig. 3]). Next, insertion of the novel dilation device was attempted, and it was easily inserted into the biliary tract. Subsequently, bile juice was aspirated and contrast medium was injected. On cholangiography, a common bile duct stone was observed. A 0.025-inch guidewire was inserted through the side hole of the novel dilator ([Fig. 4]). After tract dilation, an 8.5-Fr stent delivery system was easily inserted and successfully deployed from the intrahepatic bile duct to the stomach ([Fig. 5]) without any adverse events ([Video 1]). After the cholangitis resolved, antegrade removal of the stone was successfully performed.

Fig. 2 The diameter of the intrahepatic bile duct is only 1 mm (arrow).

Fig. 3 After successful bile duct puncture using 22 G needle, a 0.018-inch guidewire is inserted.

Fig. 4 A 0.025-inch guidewire is inserted through the side hole of the novel dilator.

Fig. 5 After tract dilation, an 8.5-Fr stent delivery system is easily inserted and successfully deployed from the intrahepatic bile duct to the stomach.

Successful endoscopic ultrasound-guided hepaticogastrostomy using a novel double-lumen tapered dilator combined with a 22 G needle.Video 1

In conclusion, this dilation device may be useful for EUS-HGS using a 22 G needle combined with a 0.018-inch guidewire. Additional cases are needed to further evaluate this device.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Isayama H, Nakai Y, Matsuda K. et al. Proposal of classification and terminology of interventional endoscopic ultrasonography/endosonography. Dig Endosc 2025; 37: 5-17
• 2 Binda C, Dajti E, Giuffrida P. et al. Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy: a meta-regression analysis. Endoscopy 2024; 56: 694-705
• 3 Kamal F, Khan MA, Lee-Smith W. et al. Efficacy and safety of EUS-guided biliary drainage for benign biliary obstruction – A systematic review and meta-analysis. Endosc Ultrasound 2023; 12: 228-236

Publication History

Article published online:
18 February 2025