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A prerequisite for endoscopic ultrasound (EUS)‐guided hepaticogastrostomy (HGS) is adequate dilation of the intrahepatic bile duct. Compared with a 19G needle, the 22G needle offers more flexible manipulation and superior ability to achieve bile duct puncture. However, evidence regarding EUS‐HGS using a 22G needle remains limited. The present study evaluated the feasibility and safety of EUS‐HGS using a novel 0.018‐inch guidewire and 22G needle for patients with insufficient intrahepatic bile duct dilation. If the bile duct diameter was <1.5 mm, a 22G needle was used, and the diameter was ≥1.5 mm; puncture with a 19G needle was first attempted, with the 22G needle being inserted if initial bile duct puncture failed. EUS‐HGS using the 22G needle was attempted in a total of 10 patients, including one patient with failed insertion of a 19G needle. Median diameter of the puncture site was 1.2 mm (range 0.5–2.5 mm). Bile duct puncture using the 22G needle was successful in all patients. Insertion of the novel 0.018‐inch guidewire was also successful in all patients. However, since tract dilation using an ultra‐tapered mechanical dilator failed in two patients, tract dilation was performed using a balloon dilator. Finally, stent deployment was successfully performed in all patients. EUS‐HGS using a 22G needle with a novel 0.018‐inch guidewire appears safe and feasible. [ABSTRACT FROM AUTHOR]

Background: With endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), guidewire manipulation might be a critically limiting step for nonexperts. However, the causes of difficult guidewire manipulation remain unclear. The aim of this study was to evaluate factors associated with successful guidewire manipulation.Methods: This retrospective cohort study included consecutive patients who underwent EUS-HGS between October 2018 and October 2019. We measured scope angle between the long and needle axes of the echoendoscope using still fluoroscopic imaging immediately after puncturing the intrahepatic bile duct. Factors associated with successful guidewire insertion were assessed by multivariable analysis using logistic regression.Result: The influence of the angle between the fine-needle aspiration (FNA) needle and echoendoscope on failed guidewire insertion was assessed using receiver operating characteristic (ROC) curves. Area under the ROC curve was 0.86 (95 % confidence interval [CI] 0.00 - 0.76), and an angle of 135° offered 88.0 % sensitivity and 82.9 % specificity for predicting successful guidewire insertion. According to multivariable analysis, only angle between the FNA needle and echoendoscope > 135° was independently associated with successful guidewire insertion (odd ratio 0.03, 95 %CI 0.01 - 0.14; P < 0.05), whereas sex, puncture site, and diameter of puncture site were not significant factors. After multivariable analysis, all variables were adjusted using age ≥ 70 or < 70 years, yielding the same results.Conclusion: The angle between the FNA needle and echoendoscope might be associated with successful guidewire manipulation during EUS-HGS. Adjusting this angle to 135° before puncturing the intrahepatic bile duct might be helpful in achieving successful guidewire manipulation during EUS-HGS. [ABSTRACT FROM AUTHOR]

Recently, we used a novel drill dilator (Tornus ES, Asahi Intecc) for EUS-HGS in a difficult case of this kind (Fig. The present case demonstrates that Tornus is useful for fistula dilation in difficult cases of EUS-HGS. [Extracted from the article]