Recently, endoscopic ultrasound (EUS)-guided biliary drainage has been developed as an alternative biliary drainage technique for failed endoscopic retrograde cholangiopancreatography (ERCP) or inaccessible papilla. Among the various EUS-guided biliary drainage procedures, EUS-guided hepaticogastrostomy (HGS) can be performed in patients with surgically altered anatomy. More recently, various transluminal treatments have been described after EUS-HGS, such as antegrade stone removal. In patients with hepaticojejunostomy strictures, stone extraction into the intestine might be challenging even after performing hepaticojejunostomy stricture dilation using a balloon catheter. In such cases, transluminal stone removal is considered an alternative method. With transluminal stone removal, a small stone that escapes from the conventional basket or from a balloon catheter could migrate into the branch bile ducts. The novel spiral basket catheter available in Japan.The wires form a helix shape, wherein each wire is wound counterclockwise, and the winding pitch becomes gradually tighter from the proximal portion to the tip. As the winding pitch is smaller and the wires are in closer contact with the bile duct wall as compared with conventional basket catheter, small bile duct stones can be easily captured by simply pulling back the catheter while the basket is open. In addition, even during withdrawal inside the bile duct, a high retrieval performance is assured by the special design that maintains the opening width on the top end. Therefore, transluminal stone removal using this novel basket catheter might be clinically useful, although further prospective evaluation of a larger number of cases is needed.

Background and Aim Bilateral stent deployment for malignant biliary obstruction (MHBO) can be achieved using side‐by‐side (SBS) or stent‐in‐stent (SIS) procedures. Compared with SBS techniques, the procedural steps of SIS are technically complex due to the necessity of introducing the delivery system into a contralateral biliary tract through the mesh of the SEMS. To overcome this issue, a novel uncovered SEMS, the HILZO Moving Cell Stent (MCS) has been released. The present study examined the technical feasibility of treating MHBO using bilateral deployment of this novel stent without dilating the mesh of the first stent to achieve insertion of the second stent within a single session, using a prospective, multicenter setting. Method The primary outcome in the present study was the technical success rate. Technical success was defined as deployment of bilateral MCSs into two or more biliary tracts using SIS without a dilation device in a single‐session. Results A total of 27 patients with complications of MHBO were enrolled in this study. Bilateral SIS using two MCS was successfully performed in 23 patients without using dilation devices among 27 patients (initial technical success rate; 85.2%). Median time to recurrent biliary obstruction (TRBO) was 271 days. Stent dysfunction was observed in 12 patients (44.4%), and re‐intervention was successfully performed in all patients without one patient who instead received best supportive care. Conclusions The SIS technique using MCS without dilation of the mesh may be technically feasible and safe. In addition, this may be useful for re‐intervention. Further comparative randomized trials are needed.

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Pancreatic duct stenting is a feasible technique for the treatment of symptomatic pancreatic duct obstruction. However, pancreatic obstruction because of impaction of large pancreatic duct stones makes the insertion of various devices, including plastic stents, challenging. Recently, a novel stent delivery system with a dilation function (EndoSheather; Piolax Medical Devices, Kanagawa, Japan) has become available in Japan. The diameter of the outer sheath of this device is 7.2Fr, and that of the inner sheath is 5.9Fr. In addition, the tip of this device is extremely tapered (3.9Fr), conforming to a 0.035-inch guidewire. These characteristics allow for easier penetration of the stricture site, and after removal of the inner sheath, various devices less than 5.9Fr in size can be inserted. A recently available small-caliber plastic stent (5Fr, Through & Pass Type IT; Gadelius Medical, Tokyo, Japan) can also be inserted within this outer sheath. We herein describe technical tips for a novel pancreatic duct stent technique using the EndoSheather, which is called the "Molting technique" (a). A 49-year-old man was admitted to our hospital to be treated for frequent pancreatitis because of impaction of a large pancreatic duct stone, for which endoscopic retrograde cholangiopancreatography was attempted. Although a 0.025-inch guidewire was successfully advanced into the main pancreatic duct across the pancreatic stone, several devices, including a Soehendra stent retriever, could not be inserted. Therefore, EndoSheather insertion was attempted. Although this device was successfully inserted, the tip of the device barely passed through the site of obstruction. Subsequently, the inner sheath of the EndoSheather was removed, and a small-caliber plastic stent was inserted into the outer sheath. Finally, we removed the outer sheath and retained the plastic stent (b). He discharged without any adverse events and also underwent contentious stent exchange. The presented technique might be useful for pancreatic duct stenting in challenging cases. Watch the Video, Supplementary Digital Content 1, http://links.lww.com/AJG/C469.

No abstract