Figure 2.

Hepaticogastrostomy (HGS). Patient with pancreatic cancer for more than 1 year and prior ERCP with metal stent placement (stent ends seen at arrows). Now with occluded stent and complete duodenal obstruction due to cancer progression. (A) Transgastric puncture and cholangiogram show indwelling self-expandable metal biliary stent (stent ends seen at arrows) with tumour overgrowth and tumour ingrowth; (B) Guidewire passage into the biliary tree with balloon dilation being performed. Note balloon dilation always begins well distal to the puncture site and progresses proximally; (C) Placement of covered self-expandable metal stent across the HGS (stent ends seen at arrows). A 7 Fr double pigtail was subsequently placed through the SEMS (not shown). Note, the patient underwent endoscopic gastrojejunostomy at the same session following HGS. ERCP, endoscopic retrograde cholangiopancreatography; SEMS, self-expanding metal stents.