Post written by So Nakaji, MD, from the Department of Gastroenterology, Kameda Medical Center, Chiba, Japan.

EUS-guided hepaticogastrostomy (EUS-HGS) can be performed by either first injecting the contrast medium or inserting the guidewire. Each method has advantages and disadvantages.

It is desirable to inject the contrast medium with a guidewire loaded in a needle such as an ERCP cannula. To cope with this issue, a needle with a Y-connector was used in this case report. The bile duct was punctured with a 19-gauge needle loaded with a 0.018-inch guidewire and filled with contrast medium through a Y-connector.

After the puncture, bile juice reflux was visually confirmed by applying negative pressure using a syringe. We then inserted the guidewire into the bile duct, advanced it slightly to the hepatic hilar side, and injected contrast medium to obtain the bile duct image.

Subsequently, we advanced it to the extrahepatic bile duct and removed the puncture needle with an indwelling guidewire. Finally, a partially covered self-expandable metallic stent with a slim delivery system and tapered tip was placed directly without dilation. The procedure was completed within 19 minutes. No procedure-related adverse events were observed.

If a 19-gauge needle loaded with a 0.025-inch guidewire is used, aspirating the bile juice and pushing out the contrast medium would be difficult because the guidewire narrows the needle’s inner circumference. However, the combination of a 19-gauge needle and a 0.018-inch guidewire allows easy aspiration and injection.

In conclusion, the combination of a 19-gauge needle and a 0.018-inch guidewire with a Y-connector during EUS-HGS may potentially reduce the incidence of adverse events by simplifying the procedure and shortening procedure time.

A partially covered gastroduodenal stent (Niti-S COMVI Pyloric/duodenal Stent; Taewoong Medical, Seoul, Korea) was additionally placed by the stent-in-stent technique. However, the duodenoscope could not pass through the stent because of residual stenosis near the center of the stent (arrows).

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