A novel approach to facilitate guidewire placement in endoscopic ultrasound-guided biliary drainage

In cases that are refractory to endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a preferred alternative ¹ . For a hepaticogastrostomy (HGS) or hepaticogastric anastomosis with stent placement, puncture of the left intrahepatic bile duct, typically segment II (B2) or segment III (B3), via the stomach is standard; however, a common challenge, irrespective of the segment chosen, is inadvertent advancement of the guidewire into the peripheral intrahepatic ducts. instead of toward the common hepatic duct (CHD) ^{2 3} . While partial needle retraction into the hepatic parenchyma may facilitate guidewire redirection in some cases, this maneuver is often suboptimal ⁴ . To address this challenge, we employed a rotatable needle knife to redirect the guidewire ( Video 1 ).

Download video file ^{(23.8MB, mp4)}

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is successfully performed after initial attempts to advance the guidewire into the common hepatic duct (CHD) through a 19-gauge needle placed into the B3 intrahepatic bile duct failed, and a rotatable needle knife was instead used, which allowed the guidewire to be advanced into the distal common bile duct and, ultimately, into the CHD, with EUS-BD completed by insertion of a stent.

Video 1

A 56-year-old man presented with obstructive jaundice secondary to pancreatic head malignancy. Following unsuccessful ERCP, he underwent EUS-BD via the stomach. Under EUS guidance, the B3 intrahepatic bile duct was punctured using a 19-gauge needle ( Fig. 1 a ) and a 0.035-inch guidewire was introduced. The guidewire was initially advanced peripherally within the intrahepatic ducts ( Fig. 1 b ). Despite multiple attempts to redirect it toward the CHD by partially withdrawing the needle, the maneuver was unsuccessful ( Fig. 2 a ).

Fig. 1.

Endoscopic ultrasound images showing: a the intrahepatic bile duct being punctured by a 19G needle; b the guidewire being advanced peripherally within the intrahepatic ducts.

Fig. 2.

Fluoroscopic images showing: a unsuccessful guidewire placement; b the rotatable needle knife being used; c successful placement of the guidewire after rotation of the needle knife within the duct.

Subsequently, we replaced the needle with a rotatable needle knife, which was advanced into the bile duct ( Fig. 2 b ). Under combined fluoroscopic and EUS guidance, the needle knife was rotated 180° within the duct, which allowed the guidewire to be successfully redirected toward the hilum ( Fig. 2 c ). The guidewire was then advanced into the distal common bile duct, enabling completion of the hepaticogastric anastomosis with stent placement. The patient recovered uneventfully with no procedure-related adverse events.

This case demonstrates that the rotatable needle knife can serve as a safe and effective adjunctive technique for guidewire redirection during EUS-BD when conventional wire manipulation fails.

Endoscopy_UCTN_Code_TTT_1AS_2AH

Endoscopy E-Videos https://eref.thieme.de/e-videos .

E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos .