EUS-guided biliary interventions for benign diseases and unsuccessful ERCP – a prospective unicenter feasibility study on a large consecutive patient cohort

2021 ◽  
Vol 59 (09) ◽  
pp. 933-943
Author(s):  
Frank Füldner ◽  
Frank Meyer ◽  
Uwe Will
Keyword(s):  
Bile Duct ◽  
Complication Rate ◽  
Bile Ducts ◽  
Clinical Success ◽  
Plastic Stents ◽  
Metal Stents ◽  
Papilla Of Vater ◽  
Complication Rates ◽  
Stone Extraction ◽  
Benign Diseases

Abstract Background and study aim Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of biliary obstruction of any etiology. However, cannulation failure of the common bile duct (CBD) by ERCP occurs in 5–10%. Alternatives after a failed ERCP are re-ERCP by an expert endoscopist, percutaneous transhepatic cholangio drainage (PTCD), (balloon) enteroscopy-assisted ERCP, or surgery. Endoscopic ultrasonography-guided drainage of the bile ducts (EUS-BD) is becoming the standard of care in tertiary referral centers for cases of failed ERCP in patients with malignant obstruction of the CBD. In expert hands, EUS-guided biliary drainage has excellent technical/clinical success rates and lower complication rates compared to PTCD. Despite the successful performance of EUS-BD in malignant cases, its use in benign cases is limited. The aim of this study (design, systematic prospective clinical observational study on quality assurance in daily clinical practice) was to evaluate the efficacy and safety of EUS-BD in benign indications. Patients and methods Patients with cholestasis and failed ERCP were recruited from a prospective EUS-BD registry (2004–2020). One hundred and three patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal = 474). Indications of EUS-BDs included surgically altered anatomy (n = 65), atypical bile duct percutaneous transhepatic cholangio orifice at the duodenal junction from the longitudinal to the horizontal segment (n = 1), papilla of Vater not reached due to the gastric outlet/duodenal stenoses (n = 6), papilla that cannot be catheterized (n = 24), and proximal bile duct stenosis (n = 7). The primary endpoint was technical and clinical success. Secondary endpoints were procedure-related complications during the hospital stay. Results 103 patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal=474). Different transluminal access routes were used to reach the bile ducts: transgastric (n = 72/103); -duodenal (n = 16/103); -jejunal (n = 14/103); combined -duodenal and -gastric (n = 1/103). The technical success rate was 96 % (n = 99) for cholangiography. Drainage was not required in 2 patients; balloon dilatation including stone extraction was sufficient in 17 cases (16.5 %; no additional or prophylactic insertion of a drain). Transluminal drainage was achieved in n = 68/103 (66 %; even higher in patients with drain indication only) by placement of a plastic stent (n = 29), conventional biliary metal stents (n = 24), HotAXIOS stents (n = 5; Boston Scientific, Ratingen, Germany), Hanaro stents (n = 6; Olympus, Hamburg, Germany), HotAXIOS stents and plastic stents (n = 1), HotAXIOS stents and metal stents (n = 1) and metal stents and plastic stents (n = 2). Techniques for stone extraction alone (nSuccessful=17) or stent insertion (nTotal = 85; nSuccessful=85 – rate, 100 %) and final EUS-BD access pathway included: Rendezvous technique (n = 14/85; 16.5 %), antegrade internal drainage (n = 20/85; 23.5 %), choledochointestinostomy (n = 7/85; 8.2 %), antegrade internal and hepaticointestinostomy (n = 22/85; 25.9 %), hepaticointestinostomy (n = 21/85; 24.7 %), choledochointestinostomy and hepaticointestinostomy (n = 1/85; 1.2 %).The complication rate was 25 % (n = 26) – the spectrum comprised stent dislocation (n = 11), perforation (n = 1), pain (n = 2), hemorrhage (n = 6), biliary ascites/leakage (n = 3) and bilioma/liver abscess (n = 3; major complication rate, n = 12/68 – 17.6 %). Re-interventions were required in 19 patients (24 interventions in total). Discussion EUS-BD can be considered an elegant and safe alternative to PTCD or reoperation for failed ERCP to achieve the necessary drainage of the biliary system even in underlying benign diseases. An interventional EUS-based internal procedure can resolve cholestasis, avoid PTCD or reoperation, and thus improve quality of life. Due to the often complex (pathological and/or postoperative) anatomy, EUS-BD should only be performed in centers with interventional endoscopy/EUS experience including adequate abdominal surgery and interventional radiology expertise in the background. This enables adequately adapted therapeutic management in the event of challenging complications. It seems appropriate to conduct further studies with larger numbers of cases to systematize the approach and peri-interventional management and to successively develop specific equipment.

scholarly journals ENDOSCOPIC TREATMENT OF POST-LIVER TRANSPLANTATION ANASTOMOTIC BILIARY STRICTURE: systematic review andmeta-analysis

2014 ◽  
Vol 51 (3) ◽  
pp. 240-249 ◽  
Author(s):  
Lucas Souto NACIF ◽  
Wanderley Marques BERNARDO ◽  
Luca BERNARDO ◽  
Wellington ANDRAUS ◽  
Lucas TORRES ◽  
...  
Keyword(s):  
Systematic Review ◽  
Liver Transplantation ◽  
Endoscopic Treatment ◽  
Clinical Success ◽  
Controlled Trial ◽  
Balloon Dilation ◽  
Plastic Stents ◽  
Metal Stents ◽  
Complication Rates ◽  
Biliary Strictures

Context Biliary strictures after liver transplantation are recognized as its Achilles’ heel. The strictures are classified in anastomotic and ischemic or non-anastomotic biliary strictures, and they figure among the most common complications after liver transplantation. There are some treatment options including balloon dilation, the placement of multiple plastic stents and the placement of self-expandable metal stents and all of them seem to have good results. Objectives The aim of this study was to systematically review the literature concerning the results of the endoscopic treatment of anastomotic biliary strictures after liver transplantation. Methods A systematic review of the literature was performed on the management of anastomotic biliary strictures post- orthotopic liver transplantation. The Medline-PubMed, EMBASE, Scielo-LILACS, and Cochrane Databases were electronically searched from January 1966 to April 2013. Results No well-designed randomized controlled trial was found. Most studies were retrospective or prospective comparisons in design. One study (86 patients) compared the endoscopic and the percutaneous accesses. The sustained clinical success rates were similar but the treatment duration was longer in the percutaneous group access. Two studies (56 patients) compared balloon dilation with balloon dilation and multiple plastic stents. There were no differences concerning sustained clinical success and complication rates. Conclusions Balloon dilation is as effective as balloon dilation plus multiple plastic stenting for the resolution of the anastomotic biliary strictures. Well-designed randomized trials are still needed to compare balloon dilation versus multiple plastic stenting versus metallic stenting.

scholarly journals Differentiated approach of using extraction balloon catheters in endoscopic biliary surgery

2021 ◽  
Vol 26 (3) ◽  
pp. 123-134
Author(s):  
A. E. Kotovskiy ◽  
B. M. Magomedova ◽  
K. G. Glebov ◽  
A. A. Martyntsov ◽  
A. K. Mahmudova ◽  
...  
Keyword(s):  
Bile Duct ◽  
Bile Ducts ◽  
Balloon Catheter ◽  
Main Function ◽  
Biliary Surgery ◽  
Benign Diseases ◽  
Balloon Catheters ◽  
Tumor Lesion ◽  
Endoscopic Extraction ◽  
Design Characteristics

Aim. Expand and determinate indications for using of extraction balloon catheters in endoscopic biliary surgery, as an additional and auxiliary endoscopic technique, which optimizes the technical conditions for performing medical and diagnostic tasks.Material and methods. We used disposable two- and three-lumen extraction balloon catheters with a diameter of 7.5 Fr. The catheters assumed delivery of an extractor balloon along a conductor with a diameter of 0.35 in into the bile duct, and also made it possible to inject a radiopaque substance. 136 retrograde endoscopic interventions were performed on the bile ducts using extraction balloon catheters.Research results. Indications for the use of an extractor balloon have been determined and proposed as a conventional standard. Interventions on the bile ducts were carried out using only a balloon catheter and in combination with a Dormia basket (n = 61). An extraction balloon catheter was used during retrograde endoscopic intervention on the bile ducts as an additional diagnostic endoscopic manipulation to facilitate the performance of the diagnostic task (n = 38). The device was also used to optimize the technical conditions of medical and diagnostic tasks (n = 37). 116 patients had benign diseases, 20 patients had tumor lesion.Сonclusion. The main function of an extraction balloon catheter is to move or displace the contents from the proximal to the distal parts of the bile duct, followed by its extraction into the duodenum. The design characteristics of the instrument make it possible to significantly expand the indications for its use, including not for its intended purpose, but as an additional method, optimizes the technical conditions for performing medical and diagnostic tasks. The endoscopic extraction balloon catheter is a multipurpose instrument that can be used to solve both diagnostic and therapeutic tasks of retrograde interventions on the bile ducts.

scholarly journals Automatic Intrahepatic Biliary Segmentation Based Image Processing Techniques using Magnetic Resonance Images

2020 ◽  
Author(s):  
Mohammad Atallah AL-Oudat ◽  
Mohammad AL Oudat ◽  
Hazem Migdady ◽  
Tariq AL Munaizel ◽  
Mohammad Awni Mahmoud ◽  
...  
Keyword(s):  
Bile Duct ◽  
Magnetic Resonance ◽  
Bile Ducts ◽  
Medical Condition ◽  
Biliary Tree ◽  
Extraction Process ◽  
Magnetic Resonance Images ◽  
Papilla Of Vater ◽  
Feed Forward Neural Network ◽  
Important Indicator

Abstract A set of tubes known as bile ducts connects the liver to an organ below it directly that is called Gallbladder. The dilation of a bile duct is an important indicator regarding any serious issue in the human body. Number of reasons may cause bile duct dilation, such as: stones, tumors which commonly occur due to pancreas or papilla of vater. In this paper, the main contributions are: 1) a novel framework that consists of three phases to be applied on a set of Magnetic Resonance Imaging (MRI) images 2) an extracted set of features with their accurate values that express the condition of the biliary trees from the MRI images. Such dataset can be used in several applications to determine whether a bile duct is dilated or not. The dataset is organized as the following: half of the MRI images are for normal bile ducts, while the other half is for dilated bile ducts. To extract the useful features to diagnose the medical condition of the bile ducts from the MRI images, we implemented and applied the proposed framework that is started by using the enhanced active contour technique without edges in combination with Denoising Convolutional Neural Networks (DnCNN) to perform the segmentation and features extraction process. After that, the output of the segmentation process is the segmented biliary tree that will be used later to extract the needful features to make a diagnostic decision whether there is a dilation or not by comparing the features values of the normal versus the dilated bile ducts. We applied the feed forward neural network with backpropagation training algorithm for classification purposes. According to the experiments, the overall accuracy of the proposed framework was 90.00%. Such approach improves and increases the accuracy of the physicians’ diagnostic decisions which is considered as of significant importance for treatment and cure.

scholarly journals Does a Fibula-Sparing Approach Improve Outcomes in Tibiotalocalcaneal Arthrodesis?

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0049
Author(s):  
Mark Wu ◽  
Daniel J. Scott ◽  
Adam P. Schiff ◽  
Manuel J. Pellegrini ◽  
James K. DeOrio ◽  
...  
Keyword(s):  
Complication Rate ◽  
Clinical Success ◽  
P Value ◽  
Complication Rates ◽  
Union Rate ◽  
Salvage Operation ◽  
Non Union ◽  
Fusion Procedure ◽  
Tibiotalocalcaneal Arthrodesis ◽  
Screw Augmentation

Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is generally considered a salvage operation for either complex deformity or arthritis about the hindfoot. Several methods can be used to achieve a TTC arthrodesis, including: intramedullary nail fixation, screws, plates, and a fine wire frame. We hypothesized that fibula sparing TTC arthrodesis would improve the union rate and decrease complications in TTC arthrodeses. To best of our knowledge, this is the largest study of TTCs in current literature and no comparative studies have been performed to investigate whether fibular resection influences union and complication rate. Methods: After obtaining approval from the IRB, a retrospective review of the TTC fusions performed at a single academic institution was performed. Orthopaedic surgeons specializing in foot and ankle surgery performed all operations. Eligible patients included those whom underwent a TTC fusion either with or without fibular resection constructs from 2005 to 2017, were 18 years or older at the time of surgery, and had at least two-year follow-up. Patients were excluded if their clinical or radiographic data were unavailable for review. Preoperative diagnosis and indications, fixation methods, clinical success, and complications were obtained from the patient chart and operative reports. 152 patients (155 ankles) underwent TTC arthrodesis, mean age 57.5 years. 94 ankles comprised the fibula-sparing group and 61 comprised the fibular resection group. Statistical analysis was performed using t-Student and Chi-squared test with a p-value of 0.05 defining significance. Results: Common diagnoses included: arthritis (n=66), prior non-union of the ankle or subtalar joint (42), Charcot neuro- arthropathy (25), failed total ankle arthroplasty (TAA) (21) and avascular necrosis of the talus (36). Pre-operative diagnosis of failed TAA was associated with post-operative nonunion (47.6%, p=0.029). In 108 ankles (70%), hindfoot intramedullary arthrodesis nailing was performed, with supplemental plating or screw augmentation in 39 cases. Plating was used in 46 patients (30%). There was no difference in complications (p=0.62) or nonunion (p=0.11) between plating vs nail arthrodesis. There was no difference in non-union rate (26% fibula-resection vs 29% fibula-sparing, p=0.74) or complication rate (49% in fibula-resection vs 53% fibula-sparing, p=0.63) in the fibula-resection compared to the fibula-sparing groups. Most common complications included: non-unions, hardware irritation/failure (17.4%), infection (16.1%), and tibial stress fractures (8.4%). Conclusion: Tibiotalocalcaneal arthrodesis is used primarily as a salvage operation for severe deformity, arthritis of both the ankle and subtalar joints, and situations in which bone loss necessitates a larger fusion procedure. There appears to be no difference in the union rate or complication rates in fibula-sparing or fibula resection during the approach for these fusion operations.

scholarly journals Incomplete Annular Pancreas with Ectopic Opening of the Pancreatic and Bile Ducts into the Pyloric Ring: First Report of a Rare Anomaly

2016 ◽  
Vol 10 (2) ◽  
pp. 373-380 ◽  
Author(s):  
Shinjiro Kobayashi ◽  
Horoyuki Hoshino ◽  
Kouhei Segami ◽  
Satoshi Koizumi ◽  
Nobuyuki Ooike ◽  
...  
Keyword(s):  
Bile Duct ◽  
Bile Ducts ◽  
Extrahepatic Bile Duct ◽  
Annular Pancreas ◽  
Papilla Of Vater ◽  
Duodenal Stenosis ◽  
Pyloric Ring ◽  
Ventral Pancreas ◽  
Bile Excretion ◽  
Small Holes

The patient was a 56-year-old woman who had experienced epigastralgia and dorsal pain several times over the last 20 years. She was admitted for a diagnosis of acute cholecystitis, and severe intra- and extrahepatic bile duct dilatation with inner air density was noted. No papilla of Vater was present in the descending duodenum, and 2 small holes were present in the pyloric ring. Bile excretion from one of the small holes was observed under forward-viewing endoscope. It was considered that the pancreatic and bile ducts separately opened into the pyloric ring. Based on these findings, malformation of the pancreaticobiliary duct was diagnosed. She did not wish treatment, but the obstruction associated with duodenal stenosis was noted after 2 years. Pancreatoduodenectomy was performed as curative treatment for duodenal stenosis and retrograde biliary infection through the bile duct opening in the pyloric ring. The ventral pancreas encompassed almost the entire circumference of the pyloric ring, suggesting a subtype of annular pancreas. Generally, lesions are present in the descending part of the duodenum in an annular pancreas, and the pancreatic and bile ducts join in the papillary region. However, in this patient, (1) the pancreas encompassed the pyloric ring, (2) the pancreatic and bile ducts opened separately, and (3) the openings of the pancreatic and bile ducts were present in the pyloric ring. The pancreas and biliary tract develop through a complex process, which may cause various types of malformation of the pancreaticobiliary system, but no similar case report was found on a literature search. This case was very rare and could not be classified in any type of congenital anomaly of the pancreas. We would classify it as a subtype of annular pancreas with separate ectopic opening of the pancreatic and bile ducts into the pyloric ring.

scholarly journals Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video)

2017 ◽  
Vol 05 (05) ◽  
pp. E395-E401 ◽  
Author(s):  
Gianfranco Donatelli ◽  
Jean-Loup Dumont ◽  
Fabrizio Cereatti ◽  
Thierry Tuszynski ◽  
Bertrand Vergeau ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Complication Rate ◽  
Endoscopic Sphincterotomy ◽  
Clinical Success ◽  
Balloon Dilation ◽  
Common Bile Duct Stones ◽  
Complication Rates ◽  
Biliary Sphincterotomy ◽  
Increased Risk ◽  
Dilation Group

Abstract Background and study aims Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP. Patients and methods From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 – 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features. Results Technical success was achieved in all cases (100 %).Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months.12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation. Conclusions Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.

scholarly journals Comparative Randomized Multicenter Study Of Plastic Vs. Self-expanding Metal Stents In The Endoscopic Ultrasound-guided Drainage Of Walled-off Pancreatic Necrosis

2019 ◽  
Author(s):  
joan b gornals ◽  
Manuel Perez-Miranda ◽  
Enrique Vazquez-Sequeiros ◽  
Juan Vila ◽  
Jose M Esteban ◽  
...  
Keyword(s):  
Endoscopic Ultrasound ◽  
Clinical Success ◽  
Fluid Collection ◽  
Plastic Stents ◽  
Metal Stents ◽  
Controlled Clinical Trial ◽  
Pancreatic Fluid Collection ◽  
Pancreatic Fluid ◽  
Tertiary Hospitals ◽  
Walled Off Necrosis

Abstract Background: It seems that the appearance of lumen-apposing metal stents (LAMS), are displacing the role of plastic stents in the therapy of pancreatic fluid collection as walled-off necrosis (WON). To date there is no quality of evidence to recommend LAMS as the standard treatment in management of WON. The theoretical benefit of LAMS over PLASTIC stents, need to be proved.Methods/design: This is a multicenter prospective study, superiority, randomized controlled clinical trial by parallel groups, without masking. One hundred fourteen patients with WON will be Endoscopic ultrasound (EUS)-guided transmural drained in 9 tertiary hospitals in Spain and will be randomized to the LAMS or PLASTIC stent group. The primary endpoint is to assess the short-term (4 weeks) clinical success determined by the reduction of the collection (to <50% or < 5cm in size), along with clinical improvement. Secondary endpoints: the long-term (4 months) clinical success (total resolution or 5cm); the procedure’s duration, the level of difficulty, safety and recurrences.Discussion: The PROMETHEUS trial has been designed to response if LAMS are superior over PLASTIC stents in the EUS-guided transmural drainage of WON. Trial registration: ClinicalTrials.gov, NCT03100578. Registered on April 4, 2017. https://clinicaltrials.gov/ct2/home

scholarly journals Multicenter study of plastic vs. self-expanding metal stents in endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis – PROMETHEUS: a randomized controlled trial protocol

Trials ◽  
2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Joan B. Gornals ◽  
◽  
Manuel Perez-Miranda ◽  
Enrique Vazquez-Sequeiros ◽  
Juan Vila ◽  
...  
Keyword(s):  
Endoscopic Ultrasound ◽  
Clinical Success ◽  
Controlled Trial ◽  
Fluid Collection ◽  
Plastic Stents ◽  
Metal Stents ◽  
Pancreatic Fluid Collection ◽  
Randomized Controlled ◽  
Link Type ◽  
Walled Off Necrosis

Abstract Background It seems that lumen-apposing metal stents (LAMS) are displacing plastic stents in the therapy of pancreatic-fluid collection in walled-off necrosis (WON). To date, there is no quality of evidence to recommend LAMS as the standard treatment in the management of WON. The theoretical benefit of LAMS over plastic stents needs to be proven. Methods/design This is a randomized controlled, multicenter, prospective clinical trial with two parallel groups, without masking. One-hundred and fourteen patients with WON will undergo endoscopic ultrasound (EUS)-guided transmural draining in nine tertiary hospitals in Spain and will be randomized to the LAMS or plastic-stent group. The primary endpoint is the short-term (4 weeks) clinical success determined by the reduction of the collection (to < 50% or < 5 cm in size), along with clinical improvement. Secondary endpoints: long-term (4 months) clinical success (total resolution or 5 cm), procedure duration, level of difficulty, safety, and recurrences. Discussion The PROMETHEUS trial has been designed to determine whether LAMS are superior to plastic stents in EUS-guided transmural drainage of WON. Trial registration ClinicalTrials.gov, ID: NCT03100578. Registered on 4 April 2017. https://clinicaltrials.gov/ct2/home

scholarly journals Clinical evaluation of physician-controlled guidewire manipulation during endoscopic ultrasound-guided hepaticogastrostomy (with video)

2021 ◽  
Vol 09 (03) ◽  
pp. E395-E400
Author(s):  
Kyohei Nishiguchi ◽  
Takeshi Ogura ◽  
Nobu Nishioka ◽  
Saori Ueno ◽  
Atsushi Okuda ◽  
...  
Keyword(s):  
Bile Duct ◽  
Success Rate ◽  
Endoscopic Ultrasound ◽  
Intrahepatic Bile Duct ◽  
Plastic Stents ◽  
Metal Stents ◽  
Success Rates ◽  
Technical Success ◽  
Technical Success Rate ◽  
Tract Dilation

Abstract Background and study aims Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) may be most complex because of the EUS-guided biliary drainage procedure and variations in the course of the intrahepatic bile duct compared with the common bile duct (CBD). Appropriate guidewire insertion is essential. Physician-controlled guidewire manipulation (PCGW) might improve technical success rates of bile duct cannulation. The present study aimed to determine the technical feasibility and safety of PCGW during EUS-HGS. Patients and methods A total of 122 consecutive patients who were scheduled to undergo EUS-HGS between October 2017 and April 2019 were prospectively registered. The primary endpoint was the technical success rate of guidewire insertion into the CBD or hepatic hilum. Guidewire insertion was considered to have failed if the HGS assistant failed to achieve manipulation. Results The intrahepatic bile duct was successfully punctured in 120 of 122 patients. During guidewire insertion by the HGS assistant, guidewire fracture was observed in one patient. The guidewire was successfully inserted into the biliary tract and manipulated by the HGS assistant in 96 patients. PCGW was thus attempted for the remaining 23 patients. The guidewire was inserted by PCGW in all 23 patients, improving the technical success rate for guidewire insertion from 80 % to 100 %. After tract dilation, we deployed covered metal stents and plastic stents in 117 and two patients, respectively. The overall technical success rate for EUS-HGS was 97.5 % (119/122). Adverse events comprising bile peritonitis or leakage developed in five patients. Conclusion PCGW might contribute to improving the success rate of EUS-HGS.

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