A 61-year-old man with obstructive jaundice caused by distal bile duct cancer recurrence was admitted to our hospital. As treatment, we performed endoscopic ultrasound-guided hepaticogastrostomy and placed a self-expanding metal stent. Computed tomography was performed immediately after the procedure to ensure proper stent placement. Although repeat imaging the next day revealed that the stent on the hepaticogastrostomy route had shortened, the stent on the gastric side maintained sufficient length. However, 11 days after the procedure, the stomach-to-liver distance had increased, and the stent on the gastric side was significantly shortened. Endoscopic imaging revealed that the stent had almost migrated, and we added a fully covered self-expanding metal stent into the previous metallic stent via the hepaticogastrostomy route. The patient was discharged 19 days after the initial procedure without complications. Computed tomography performed 40 days after the hepaticogastrostomy revealed that the initial stent had migrated into the abdominal cavity, but the second stent was in an appropriate position. In conclusion, repeated monitoring by computed tomography after hepaticogastrostomy procedure may be an effective method for preventing stent migration in high-risk cases.

A 61-year-old man with obstructive jaundice caused by distal bile duct cancer recurrence was admitted to our hospital. As treatment, we performed endoscopic ultrasound-guided hepaticogastrostomy and placed a self-expanding metal stent. Computed tomography was performed immediately after the procedure to ensure proper stent placement. Although repeat imaging the next day revealed that the stent on the hepaticogastrostomy route had shortened, the stent on the gastric side maintained sufficient length. However, 11 days after the procedure, the stomach-to-liver distance had increased, and the stent on the gastric side was significantly shortened. Endoscopic imaging revealed that the stent had almost migrated, and we added a fully covered self-expanding metal stent into the previous metallic stent via the hepaticogastrostomy route. The patient was discharged 19 days after the initial procedure without complications. Computed tomography performed 40 days after the hepaticogastrostomy revealed that the initial stent had migrated into the abdominal cavity, but the second stent was in an appropriate position. In conclusion, repeated monitoring by computed tomography after hepaticogastrostomy procedure may be an effective method for preventing stent migration in high-risk cases.

A 61-year-old man with obstructive jaundice caused by distal bile duct cancer recurrence was admitted to our hospital. As treatment, we performed endoscopic ultrasound-guided hepaticogastrostomy and placed a self-expanding metal stent. Computed tomography was performed immediately after the procedure to ensure proper stent placement. Although repeat imaging the next day revealed that the stent on the hepaticogastrostomy route had shortened, the stent on the gastric side maintained sufficient length. However, 11 days after the procedure, the stomach-to-liver distance had increased, and the stent on the gastric side was significantly shortened. Endoscopic imaging revealed that the stent had almost migrated, and we added a fully covered self-expanding metal stent into the previous metallic stent via the hepaticogastrostomy route. The patient was discharged 19 days after the initial procedure without complications. Computed tomography performed 40 days after the hepaticogastrostomy revealed that the initial stent had migrated into the abdominal cavity, but the second stent was in an appropriate position. In conclusion, repeated monitoring by computed tomography after hepaticogastrostomy procedure may be an effective method for preventing stent migration in high-risk cases.

Background/Aims: Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is performed globally, the procedure remains challenging. Guidewire manipulation is the most difficult step, and there are few reports on the factors associated with unsuccessful guidewire manipulation. This study aimed to assess the significance of the puncture angle on EUS images and identify the most effective guidewire rescue method for patients with unsuccessful guidewire manipulation. Methods: We retrospectively enrolled 115 patients who underwent EUS-HGS between May 2016 and April 2022 at two centers. The puncture angle between the needle and the intrahepatic bile duct was measured through EUS movie records. Results: Guidewire manipulation was unsuccessful in 28 patients. Receiver operating characteristic (ROC) curves identified an optimal puncture angle cutoff value of 85° (cutoff value, 85°; area under the ROC curve, 0.826; sensitivity, 85.7%; specificity, 81.6%). Multivariate analysis demonstrated that a puncture angle <85° was a significant risk factor for unsuccessful guidewire manipulation (odds ratio, 19.8; 95% confidence interval, 6.42–61.5; p<0.001). Among the 28 unsuccessful cases, 24 patients (85.7%) achieved successful guidewire manipulation using various rescue methods. Conclusions The puncture angle observed on EUS is crucial for guidewire manipulation. A puncture angle of <85° was associated with unsuccessful guidewire manipulation.