Endoscopic ultrasound-guided hepaticogastrostomy for patients with frequent respiratory fluctuations using a novel hybrid guidewire to prevent guidewire shearing

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is widely attempted in patients after failed endoscopic retrograde cholangiopancreatography (ERCP) [1] [2]. EUS-HGS requires several procedural steps, including bile duct puncture, guidewire insertion, tract dilation, and stent deployment. Among these procedural steps, guidewire insertion may be most challenging, especially in nonexpert hands [3]. A liver impaction technique may be useful for improving the technical success rate of guidewire insertion [4] [5]; however, this technique often cannot be performed, especially in patients with nondilated bile ducts or frequent respiratory fluctuations, because guidewire visualization on EUS images can be difficult.