Alternative endoscopic ultrasound-guided choledochogastrostomy for anatomical inaccessibility by usual biliary drainage methods

A 92-year-old man was admitted with jaundice and cholangitis. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) revealed intrahepatic/middle bile duct dilatation, with a pancreatic head lesion suspicious for carcinoma ([Fig. 1] a, c); the intraperitoneal organs were drawn into the right thoracic cavity due to Chilaiditi syndrome ([Fig. 1] b). Despite wire-guided insertion, endoscopic retrograde cholangiography (ERC) could not reach the papilla of Vater owing to anatomical abnormalities ([Fig. 2]). Endoscopic ultrasound-guided hepaticogastrostomy failed because of invisibility of the left intrahepatic duct. The common bile duct (CBD), which in normal anatomy is not clearly visualized from the gastric tract, could be visualized from the antrum. Endoscopic ultrasound-guided choledochogastrostomy (EUS-CGS) was ultimately performed ([Video 1]).