A safe technique using clips for covered self-expandable metal stent placement during endoscopic ultrasound-guided hepaticogastrostomy.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a new biliary drainage procedure, which uses a curved linear-array echoendoscope. Recently, the efficacy and safety of covered self-expandable metal stent (CSEMS) placement have been reported [1–5]. However, it is difficult to confirm correct release of the CSEMS endoscopically and stents can easily migrate into the abdominal cavity or intrahepatic bile duct. We report here on an innovation using clips that facilitates confirmation of the correct release point under fluoroscopic guidance. An 85-year-old woman with lymph node metastases from gastric cancer presented with lymphadenopathy that was causing bile duct and duodenal strictures. Because of the duodenal strictures, endoscopic retrograde cholangiography (ERC) could not be performed. EUS-HGS was chosen instead to relieve her obstructive jaundice. The puncture site was determined using the echoendoscope, and India ink was locally injected using a 25-gauge sclerotherapy needle (Olympus Medical Systems, Tokyo Japan;●" Fig.1a;●" Video 1). With the India ink serving as an indicator, clips (Resolution Clip Device; Boston Scientific, Natick, Massachusetts, USA) were applied to both the proximal and distal points of the injection sites (●" Fig.1b and ●" Fig.2a). The echoendoscope was again guided to themarked site for the puncture and a 19-gauge needle (Expect; Boston Scientific) was used to puncture the intrahepatic bile duct. The hole through the gastric and bile duct walls was dilated using dilation catheters and a Niti-S (end bare; 100mm×8mm) stent (TaeWoong Medical, Gimpo, Korea) was placed for EUS-HGS (●" Fig.2b). During stent deployment, the puncture site was easily identified with the two gastric mucosal markers, and the correct proximal position of