Novel wire-guided fine-gauge bougie dilator for transpapillary or endoscopic ultra- sonography-guided biliary drainage

Endoscopic management of biliary stricture generally requires dilation using devices such as an endoscopic retrograde cholangiopancreatography (ERCP) balloon dilation catheter before stenting [1]. Endoscopic ultrasonography (EUS)guided biliary drainage (EUS-BD) also requires fistula dilation before stenting. Recently, ultraslim balloon catheters [1] and diathermic dilators [2] have also been developed as dilation devices. These devices must be wire-guided, coaxial with the guidewire, fine-gauge, and sufficiently stiff. Herein, we present two patients who successfully underwent biliary dilation using a novel wire-guided fine-gauge bougie dilator (ES dilator soft type; Zeon Medical Inc., Tokyo, Japan) (▶Fig. 1 and ▶Fig. 2) for transpapillary drainage and EUS-BD. The first patient was a 79-year-old man who was admitted with obstructive jaundice having undergone placement of self-expandable metal stents (SEMSs) for perihilar bile duct cancer 5 months previously. An ERCP showed occlusion of the SEMSs (▶Fig. 3 a). First, a 0.025-inch hard-type guidewire (VisiGlide 2; Olympus, Tokyo, Japan) was advanced across the occluded SEMSs. A tapered ERCP catheter and a dilation catheter (SBDC-6; Cook Japan, Tokyo, Japan) could not be passed through the stricture (▶Video1). The novel dilator was then inserted, resulting in successful passage through the occluded SEMSs (▶Fig. 3b; ▶Video1). Finally, an uncovered SEMS was placed without any complications. The second patient was an 85-year-old man who was admitted with obstructive jaundice and a history of total gastrectomy and Roux-en-Y reconstruction for gastric cancer 21 years previously. A computed tomography (CT) scan showed an ampullary tumor and treatment by EUS-BD was selected. Firstly, B3 was punctured with a 19-gauge needle via the jejunum and a 0.025-inch hardtype guidewire (VisiGlide 2; Olympus) was placed. A tapered ERCP catheter was tried without success to dilate the fistula. Subsequently, dilation with the novel dilator was attempted, and this was successfully inserted into the intrahepatic bile duct (▶Fig. 4; ▶Video2). Finally, EUS-guided antegrade stenting E-Videos