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Gastrointestinal: Guidewire insertion under transluminal cholangioscopy guidance for a hepaticojejunostomy stricture resembling a pinhole

Hepaticojejunostomy stricture (HJS) is usually treated in the clinical setting by percutaneous transhepatic bile duct drainage or using enteroscopic guidance. Endoscopic ultrasound (EUS)-guided biliary drainage has recently been indicated as an alternative to these procedures if they fail. However, guidewire insertion into the intestine through an HJS is difficult because the HJS cannot be directly visualized. Therefore, treating an HJS that is so constricted that it resembles a pinhole using EUS guidance can be challenging. We describe technical tips for treating pinhole HJS using transluminal cholangioscopy. A 69-year-old man who was complicated with obstructive jaundice due toHJS underwent a pancreatoduodenostomy owing to cholangiocarcinoma. However, the enteroscopic approach failed, and he was referred to our hospital. An EUS-guided hepaticogastrostomy initially proceeded using a partially covered, self-expandable, Niti-S Biliary Covered Metal Stent (TaeWoong Medical, Seoul, Korea) (Fig. 1a). A cholangioscope (SPY-DS; Boston Scientific, Tokyo, Japan) was inserted into the biliary tract via the EUS-guided hepaticogastrostomy route 1 week later. The HJS was visible, with a pinhole appearance (Fig. 1b, Video S1), so a guidewire was inserted under direct visualization (Figs 1c,d; see supplementary video). Next, theHJSwas dilated using an 8-mm REN biliary balloon catheter (KANEKA Medical, Osaka, Japan) (Fig. 1e), and a type IT plastic stent was deployed (Gadelius Medical Co., Ltd., Tokyo, Japan) from the intrahepatic bile duct to the stomach without any adverse events. Transluminal cholangioscopy might be clinically useful to treat pinhole-like HJS.