Endoscopic ultrasound-guided transgastric biliary metal stent placement after dilation with tapered-tip Teflon catheters and marking with a clip.

We report the case of a 74-year-old man with known type 2 diabetes mellitus, hypertension, and retinal detachment who was referred for endoscopic retrograde cholangiopancreatography (ERCP) because of a fever and severe upper abdominal pain for a fewdays.Anultrasoundofhis upper abdomen showed a4×5-cmheterogeneous hypoechoic area in the gallbladder fossa with intrahepatic bile duct dilatation, which it was suspected was due to gallbladder cancer. He therefore proceeded to ERCP for biliary drainage. The patient was given intravenous sedation and was placed in the left lateral decubitus position. After duodenal intubation, cannulation of the common bile duct (CBD) was performed with the release of a large amount of purulent discharge (●" Fig.1). We were unable to pass the guide wire into the intrahepatic ducts because of intracavitary tumor (●" Fig.2). Therefore, we decided to perform endoscopic ultrasound (EUS)-guided antegrade stent placement using the rendezvous technique. A metal clip (Quick Clip HX-201UR-135; Olympus Medical Systems, Tokyo, Japan) was placed through the duodenoscope just beside the ampulla for localization (●" Fig.3). We then punctured segment 2 of the left lobe of the liver using a 19gauge needle guided by a curvilinear echoendoscope (GF-UE140P; Olympus, Tokyo, Japan) with color Doppler to avoid intervening vascular structures. A 0.035inch guide wire was passed down to the ampulla and the tract was dilated using tapered-tip Teflon catheters of size 7 Fr, Fig.1 View during endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage performed in a 73-year-old man with suspected gallbladder cancer showing a large amount of purulent discharge being released on deep cannulation of the common bile duct. Fig.2 Radiographic image during endoscopic retrograde cholangiopancreatography (ERCP) showing that the guide wire could not be passed across the tumor site. Fig.3 Endoscopic view showing a metal clip that had been placed through the duodenoscope positioned next to the ampulla to assist with localization.