A long-scope technique for difficult intrahepatic bile duct puncture during endoscopic ultrasound-guided hepaticogastrostomy

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During endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), the intrahepatic bile duct is conventionally punctured from the upper gastric body.[ 1​ ] [ ​2​ ] However, puncture may be challenging because of anatomical conditions.[ 3​ ] [ 4​ ] [ ​5​ ] Herein, we report a long-scope EUS-HGS technique performed from the gastric antrum as a rescue option. An 89-year-old man with distal biliary obstruction caused by unresectable pancreatic cancer underwent transpapillary stenting, followed by endoscopic duodenal stenting for malignant duodenal obstruction. Subsequently, the patient developed acute cholangitis, and an endoscopic nasobiliary drainage tube was placed through the duodenal stent mesh ([ Fig. 1 ]). Following resolution of the cholangitis, EUS-HGS was performed as an alternative biliary drainage route ([ Video 1 ]). Fig. 1 Endoscopic retrograde cholangiopancreatography through a duodenal stent. ( a ) The duodenoscope was advanced through the duodenal stent. ( b ) An endoscopic nasobiliary drainage tube was successfully placed. Video 1 A long-scope endoscopic ultrasound-guided hepaticogastrostomy technique as a rescue option when puncture from the conventional position is difficult. Download Video The B3 bile duct was visualized from the gastric body using an echoendoscope. Puncture using a 19-gauge needle proved difficult as the gastric wall and liver moved away from the scope tip. Puncture of the alternate B2 was considered; however, prominent blood vessels were present along the puncture line ([ Fig. 2 ]). Fig. 2 Intrahepatic bile duct puncture from the gastric body. ( a ) Puncture of the B3 bile duct was attempted using a 19-gauge needle (arrowheads). However, the gastric wall and liver moved apart, making puncture unsuccessful. ( b ) Puncture of the alternate B2 was considered; however, prominent blood vessels located along the puncture line preclude a safe puncture route (arrows). This patient had a cascade stomach, and preprocedural computed tomography revealed that the left hepatic lobe was near the gastric antrum ([ Fig. 3 ]). The echoendoscope was therefore advanced into the antrum and positioned in a long-scope configuration. From this position, the proximal B3 was clearly visualized and punctured using a 19-gauge needle ([ Fig. 4 ]). Following guidewire insertion, a 7-Fr plastic stent was successfully placed ([ Fig. 5 ]). No intraoperative or postoperative adverse events occurred. The patient was discharged home 4 days after the procedure and was subsequently managed with best supportive care. Fig. 3 Preprocedural contrast-enhanced computed tomography. Computed tomography reveals a cascade stomach, with the left hepatic lobe located close to the gastric antrum. ( a ) Axial image. ( b ) Coronal image Fig. 4 Endoscopic ultrasound-guided hepaticogastrostomy from the gastric antrum in the long-scope position. ( a ) Endoscopic ultrasonography from the gastric antrum clearly visualized the B3 bile duct. ( b ) The proximal B3 bile duct was successfully punctured using a 19-gauge needle (arrowheads). ( c ) A 0.025-inch guidewire was advanced into the bile duct. Fig. 5 Fluoroscopic and endoscopic images after the procedure. ( a ) A fluoroscopic image after the procedure showing the successful placement of a plastic stent in the B3 duct (arrowhead). ( b ) An endoscopic view showing the plastic stent placed via endoscopic ultrasound-guided hepaticogastrostomy along the lesser curvature of the gastric antrum (arrowhead). Arrows indicate the endoscopic nasobiliary drainage tube. The long-scope position used in this case facilitated secure access to the puncture site. This approach also improved procedural stability because the echoendoscope can be stabilized along the greater curvature of the stomach. Although further investigations are warranted to determine the optimal indications, this technique may expand the technical options for EUS-HGS in patients with the left hepatic lobe positioned close to the gastric antrum. Endoscopy_UCTN_Code_TTT_1AS_2AH Publication History Received: 23 March 2026 Accepted after revision: 19 July 2026 Article published online: 04 August 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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