Uneven double-lumen cannula for rescue guidewire technique in endoscopic ultrasonography-guided hepaticogastrostomy.

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is used after failed endoscopic retrograde cholangiopancreatography (ERCP) [1]. Manipulation of the guidewire is one of the most challenging techniques in EUSHGS.We present a successful case of rescue guidewire technique using a multilumen catheter [2], namely an uneven double-lumen cannula (Piolax Medical Devices, Yokohama, Kanagawa, Japan) (▶Fig. 1), for EUS-HGS. A 75-year-old man was admitted with obstructive jaundice due to advanced colon cancer, after right hepatectomy for liver metastasis. We attempted EUS-HGS after failed ERCP. After the left intrahepatic bile duct had been punctured using a 19-gauge needle (▶Fig. 2), a 0.025-inch hard-type guidewire (VisiGlide 2; Olympus, Tokyo, Japan) was placed. The guidewire was accidentally introduced into the peripheral bile duct (▶Fig. 3). We then inserted the ERCP catheter along the guidewire into the left intrahepatic bile duct. However, the guidewire could not be advanced to the perihilar bile duct, even after we changed to a 0.032-inch hydrophilic guidewire (Radifocus; Terumo, Tokyo, Japan). Therefore, we coiled the 0.025-inch hard-type guidewire again within the left intrahepatic bile duct, and changed the ERCP catheter to the uneven double-lumen cannula (▶Video1). This cannula was slowly withdrawn, and we were able to successfully introduce a second 0.032-inch hydrophilic guidewire to the perihilar bile duct via the 0.035-inch lumen (▶Fig. 4, ▶Video1). After changing to the hard-type guidewire (▶Fig. 5, ▶Video1), a 7-Fr plastic stent (TYPE-IT; Gadelius Medical, Tokyo, Japan) was placed for EUS-HGS without complications (▶Fig. 6, ▶Video1). In EUS-HGS, the angle at which the intrahepatic bile duct is punctured is the most important factor in successful advancement of the guidewire toward the perihilar bile duct [3]. This depends on individual anatomy, and therefore it is sometimes difficult to achieve the optimal angle for advancing the guidewire to the perihilar bile duct. The uneven doublelumen cannula facilitated guidewire manipulation during EUS-HGS when it was difficult to direct the guidewire toward the perihilar bile duct.