Endoscopic ultrasound-guided hepaticogastrostomy/hepaticojejunostomy (EUS-HGS/HJS) is an established alternative to endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy 1 2. When combined with antegrade transpapillary stenting (AGS), dual-route biliary drainage can be secured 3 4 ; however, troubleshooting often requires balloon-assisted endoscopy. A 65-year-old man with surgically altered anatomy and multiple comorbidities presented with septic shock due to choledocholithiasis-related cholangitis. Emergency EUS-HJS was performed to achieve rapid decompression because definitive stone extraction was not feasible at that time. A plastic stent was placed antegradely across the papilla (AGS), and an endoscopic nasobiliary drainage (ENBD) tube was added (Fig. 1). Two weeks later, ENBD cholangiography confirmed stone clearance, and internalization was planned because fistula maturation was uncertain and reintervention without balloon-assisted endoscopy was desirable at the receiving hospital; stent exchange via the HJS route was planned if cholangitis recurred. A standard guidewire was advanced via the ENBD and left in place as a rescue wire in case the stent migrated completely into the bowel; the ENBD tube was removed. A handmade snare was advanced through the HJS tract alongside the rescue wire. As previously reported 5, the snare was constructed by inserting both ends of a 0. 025-inch flexible hydrophilic guidewire commonly used for ERCP in Japan (Radifocus; Terumo, Japan) into the two lumens of a double-lumen catheter (Uneven Double Lumen Cannula; Piolax Medical Devices, Japan; distal outer diameter: 3. 6 Fr). Due to the limited wire length, the proximal end of the catheter was cut to externalize both wire ends, creating a soft loop with the wire exiting from the two distal holes (Fig. 2). The loop was used to grasp the stent flap and reposition the stent to the HJS anastomosis; patency was confirmed (Fig. 3, Video 1). This HJS-based technique provides a simple approach for transpapillary stent management without the need for balloon-assisted endoscopy. EndoscopyUCTNCodeCCL₁AF₂AF₃AB EndoscopyUCTNCodeTTT₁AR₂AZ Article published online: 17 February 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
Namima et al. (Tue,) studied this question.