EUS-guided hepaticogastrostomy for hepaticojejunostomy stricture using a 22G needle and a mechanical dilator (with video).

EUS-guided biliary drainage (EUS-BD) has been indicated for benign biliary strictures. However, the intrahepatic bile duct is sometimes much narrower in benign biliary strictures. In this situation, puncture of the intrahepatic bile duct using a 19-G needle is sometimes challenging. Several reports have described attempts at EUS-BD using a 22-G needle, but fistula dilation with a 22-G needle is challenging because the 0.018-inch guidewire is not stiff enough to perform dilatation. Recently, a thin mechanical dilator has become available. After its insertion into the biliary tract, the 0.018-inch guidewire can be replaced with a 0.025-inch guidewire. We herein describe the technical procedure of EUS-guided hepaticogastrostomy using a 22-G needle with a thin mechanical dilator.