Re-intervention with endoscopic ultrasound-guided hepaticogastrostomy for unresectable hilar biliary drainage using a multipath occlusion balloon.

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) and antegrade stenting (EUS-AS) have been developed as alternative biliary drainagemethods; however, treating unresectable malignant hilar biliary strictures remains challenging [1–3]. We successfully performed re-intervention for malignant hilar biliary drainage after EUS-HGS using a multipath occlusion balloon. A 46-year-old woman who was on medication for a postoperative recurrence of gastric cancer presented with jaundice. She had previously undergone doubleballoon enteroscope (DBE)-assisted biliary drainage with a self-expandablemetal stent (SEMS) for malignant biliary stricture of the lower bile duct. Contrast-enhanced computed tomography (CT) showed strictures of the hilar bile duct and duodenum (▶Fig. 1) associated with dissemination of the gastric cancer. EUS-HGS was performed (▶Fig. 2), and a 7-Fr plastic stent (TYPEIT; Gadelius Medical, Tokyo, Japan) was placed into the B3 bile duct [4]. However, the patient’s jaundice was not improved, and re-intervention was required. A 0.025-inch guidewire was placed into the duodenum beyond the papilla, and the plastic stent was removed. A second 0.025-inch guidewire was placed into the B5 bile duct using a multipath occlusion balloon (Bouncer; Cook Medical, Tokyo, Japan) (▶Fig. 3). This balloon has a multilumen located at either end of the balloon, which enables guidewires to be passed easily into crooked bile ducts (▶Fig. 3 and ▶Fig. 4 a; ▶Video1). A Zilver 635 biliary SEMS (Cook Medical, Tokyo, Japan) was introduced over the first guidewire and placed into the B5 bile duct, bridging the right and left hepatic ducts (▶Fig. 4 b). Finally, a modified Niti-S GIOBOR biliary stent (Century Medical, Tokyo, Japan) was placed into the B3 bile duct (▶Fig. 4 c). The jaundice subsequently improved, and no adverse events occurred. Endoscopy_UCTN_Code_TTT_1AR_2AZ