Efficacy of primary endoscopic ultrasound-guided biliary drainage with the placement of multiple plastic stents in the management of hepaticojejunostomy stricture: a retrospective, single-center study in Japan

Mako Ushio; Toshio Fujisawa; Ko Tomishima; Yusuke Takasaki; Shigeto Ishii; Koichi Ito; Akinori Suzuki; Daisuke Namima; Sho Takahashi; Taito Fukuma; Hiroto Ota; Daishi Kabemura; Muneo Ikemura; Ippei Ikoma; Yasuhisa Jimbo; Haruka Hagiwara; Yusuke Yamaguchi; Takumi Okuaki; Shin Arii; Hiroyuki Isayama

doi:10.5946/ce.2025.006

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Original Article Efficacy of primary endoscopic ultrasound-guided biliary drainage with the placement of multiple plastic stents in the management of hepaticojejunostomy stricture: a retrospective, single-center study in Japan: Mako Ushio, Toshio Fujisawa, Ko Tomishima, Yusuke Takasaki, Shigeto Ishii, Koichi Ito, Akinori Suzuki, Daisuke Namima, Sho Takahashi, Taito Fukuma, Hiroto Ota, Daishi Kabemura, Muneo Ikemura, Ippei Ikoma, Yasuhisa Jimbo, Haruka Hagiwara, Yusuke Yamaguchi, Takumi Okuaki, Shin Arii, Hiroyuki Isayama; Clinical Endoscopy 2025;58(6):909-917.
DOI: https://doi.org/10.5946/ce.2025.006
Published online: November 6, 2025

Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan

Correspondence: Hiroyuki Isayama Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan E-mail: h-isayama@juntendo.ac.jp

• Received: January 3, 2025 • Revised: July 22, 2025 • Accepted: August 12, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Graphical abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
NOTES
REFERENCES

Abstract

Background/Aims
Hepaticojejunostomy strictures (HJSS), recurrent cholangitis, and jaundice are major complications of surgical hepaticojejunostomy. Previously, HJSS was managed using percutaneous procedures and balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. However, endoscopic ultrasound-biliary drainage (EUS-BD) was recently reported to be an effective salvage procedure. EUS-BD as a primary drainage method using a trans-endosonographically created route (trans-ESCR) has not been previously evaluated.
Methods
We enrolled consecutive patients who underwent EUS-BD for HJSS at the Juntendo University Hospital between March 2017 and December 2022. After ESCR maturation, multiple plastic stents were placed for 1 year with or without cholangioscopic evaluation. We evaluated the technical and clinical success rates, stent removal, HJSS recurrence, and related adverse events.
Results
Thirty-seven patients required EUS-guided hepaticogastrostomy/hepaticojejunostomy (n=36/1). The technical and clinical success rates were 94.6% and 100.0%, respectively, and 17% of patients experienced adverse events. Cholangioscopy via ESCR was performed in 19 patients to evaluate the strictures and manage concomitant stones. The success rate of stent removal after multiple stent placements for more than 1 year was 83%.
Conclusions
Primary EUS-BD and trans-ESCR are feasible and effective in the management of HJSS. Further prospective studies are needed to confirm the results of this pilot study.
Keywords: Endoscopic stenting; Endoscopic ultrasound; Endoscopic ultrasound-hepaticogastrostomy/hepaticojejunostomy; Hepaticojejunostomy stricture

Graphical abstract

INTRODUCTION

Interventional endoscopic ultrasound (I-EUS) is rapidly advancing and many studies have focused on improving the efficiency of pancreatobiliary disease management. However, insurance does not cover the procedure fees for I-EUS in most countries, and dedicated devices are still unavailable. In Japan, the government insurance covers EUS-guided drainage/anastomosis (EUS-D/A) for pancreatic fluid, abdominal abscesses, gallbladder disease, and bile duct disease, and reimbursement is available for specialized devices. Guidelines for EUS-guided biliary drainage (EUS-BD) have been published in 2019.¹ There has recently been a shift toward drainage and subsequent antegrade procedures through the matured anastomosis. Recurrent cholangitis and jaundice due to stricture formation are significant complications of surgical hepaticojejunostomy, occurring in 1% to 13% of patients in a previous study.²^-⁶ Historically, hepaticojejunostomy stricture (HJSS) formation was managed by percutaneous transhepatic biliary drainage (PTBD) and related procedures. However, the efficacy of balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has recently been reported.⁷^-¹⁰ Although BE-ERCP is often effective, its success depends on the technique used, and reaching the anastomotic site may be difficult. The indication for EUS-BD was originally unresectable malignant biliary obstruction, but EUS-BD for benign biliary disease has recently been described.¹¹^,¹² Compared with BE-ERCP, EUS-BD has a shorter procedure time and lower rate of adverse events (AEs).¹³ Recent reports have described the use of a trans-endosonographically created route (trans-ESCR) and a peroral cholangioscope (POCS), even in pediatric cases.¹⁴^-¹⁶ Biliary diseases can be managed using various intra-bile duct procedures including observation, biopsy, and electrohydraulic lithotripsy (EHL), and HJSS may be successfully managed by I-EUS and related procedures. At our institution, we perform EUS-D/A as the primary drainage and trans-ESCR procedures for the management of HJSS. The basic treatment strategy after EUS-guided hepaticogastrostomy/hepaticojejunostomy (EUS-HGS/HJS) involves POCS insertion to confirm a benign stricture and placement of multiple stents for 1 year to dilate the HJSS site. In this pilot study, we retrospectively analyzed the clinical results of this strategy.

METHODS

Study design

This single-arm retrospective pilot study had no control group and was performed at a single academic center. Consecutive patients who underwent EUS-D/A for HJSS at Juntendo University Hospital between March 2017 and December 2022 were included in this study. The participating endoscopists were experts who had performed more than 100 I-EUS procedures, and all trainees were supervised by experts.

EUS-D/A for HJSS

The goals of the EUS-D/A procedure were to improve jaundice/cholangitis, create a biliary access route, confirm benign strictures, and resolve HJSS. In the patients with HJSS in the present study, we performed primary EUS-HGS or EUS-HJS without ERCP. Indications for biliary drainage were recurrent cholangitis or obstructive jaundice secondary to HJSS. Patients also underwent POCS insertion through the established EUS-HGS/HJS sites to obtain biopsy specimens, and if needed, EHL for the treatment of intrahepatic bile duct stones.

EUS-HGS/HJS was initially performed for biliary drainage in patients with jaundice/cholangitis, and biliary access was provided in those with clinical improvement. A convex echoendoscope and universal ultrasound processor (EG-580T or EG-740T and SU-1; Fujifilm) were used for all EUS-HGS/HJS procedures. All patients underwent endoscopic procedures under conscious sedation with pethidine hydrochloride, midazolam, and/or propofol, and received antibiotics after the procedure. The intrahepatic bile duct (mainly B3) was punctured using a 19-gauge needle (EZ Shot 3 Plus; Olympus) and contrast medium was injected to perform cholangiography. A 0.025-inch guidewire (VisiGlide 2; Olympus) was then inserted and advanced through the HJSS, if possible.

A two-step procedure was used to dilate the puncture route and HJSS site. The first dilation was performed using a bougie dilator (ES Dilator; Zeon Medical) or a drill dilator (Tornus ES; Kaneka). A cautery dilator was prepared for cases with mechanical dilation failure but was not required in any of the cases. A second dilation was performed using a balloon dilator. Balloon dilation procedures were performed using an ultrathin-tip 4-mm dilating balloon catheter (REN; Kaneka) at the HJSS site (if possible), bile duct entry site, liver parenchyma, and gastric wall. The double-guidewire insertion method was applied using a double-lumen catheter (Uneven Double Lumen Cannula; Piolax Medical) with insertion of a stiff 0.035-inch wire (RevoWave super hard type or RevoWave SeekMaster hard type; Piolax Medical). Plastic stents were inserted along the 0.035-inch guidewire to increase safety. A 7-Fr 15 cm double pigtail plastic stent (DPPS, Zimmon; Cook Medical) (Through & Pass; Gadelius Medical) was inserted across the trans-ESCR and HJSS. When the wire could not pass across the HJSS, a straight-type stent (Through & Pass; Gadelius Medical) (Flexima; Boston Scientific) was placed in the bile duct through the trans-ESCR. For follow-up of the initial I-EUS procedure, routine abdominal plain computed tomography was performed the following day.

Trans-ESCR procedures

Trans-ESCR procedures were used to manage symptomatic HJSS, including crushing or removing intrahepatic stones, evaluating the HJSS, balloon dilation for HJSS, and resolution of the HJSS. To dilate the HJSS, a second stent was inserted 1 to 2 months after the initial EUS-HGS/HJS procedure, with or without balloon dilation. In the second session, a 0.025-inch guidewire (VisiGlide 2; Olympus) was inserted into the ESCR next to the initially placed plastic stent, and the guidewire end was kept long in the jejunum. The same DPPS (Zimmon) was inserted into the ESCR. A POCS was inserted one week later. One DPPS was removed, and the same procedure was performed as in the second session; we then removed the other DPPS while keeping the wire in place. Next, a POCS was inserted into the bile duct to evaluate the cause of the HJSS. If intrahepatic stones were concomitantly observed, they were pushed toward the jejunum by the POCS itself or using a balloon catheter (Extractor Pro; Boston Scientific). If the stones were too large to be pushed out, Autolith Touch (EHL; Boston Scientific) was used. A biopsy of the HJSS site under POCS guidance was performed using biopsy forceps (SpyBite; Boston Scientific), and the stricture was diagnosed based on both POCS and pathological findings. The two DPPSs were exchanged every 3 months for 1 year. If the HJSS had no resolution, three DPPSs were used. After confirming the resolution of the stricture through ESCR with contrast medium, we attempted to remove the stents while ensuring a low outflow status (Fig. 1).

Definitions

We evaluated the technical and clinical success of the procedure as well as the rates of AEs. Technical success was defined as a successful EUS-HGS/HJS procedure, and clinical success was defined as improvement in new-onset jaundice/cholangitis after 2 weeks, according to the Tokyo criteria.¹⁵ We also evaluated the rate of stent removal after improvement in HJSS. When deciding whether to remove the stents, we verified the resolution of the HJSS, which was pathologically diagnosed as benign. Certification was based on contrast medium examination and the absence of stones was confirmed through POCS insertion. Recurrence was defined as the any required biliary drainage. All evaluation items were in accordance with Tokyo criteria.¹⁷

Study outcomes and analyses

The primary outcome was DPPS removal rate. Secondary outcomes were the technical and clinical success of EUS-HGS/HJS and the occurrence of procedure-related AEs. Early and late stent-related AEs were defined as those that developed within and after two weeks of the procedure, respectively. The AEs were graded according to the Tokyo criteria and published by the corresponding author of this paper. Results are expressed as medians with interquartile ranges (IQRs).

Ethical statements

All patients provided written informed consent before each procedure. This study was approved by the Institutional Review Board (IRB) of Juntendo University Hospital (IRB no. H21-0017). Informed consent for participator was provided participation through an online opt-out procedure.

RESULTS

Patient characteristics

This study enrolled 37 patients with surgically altered anatomy. The patients who required EUS-HGS (n=36) or EUS-HJS (n=1) and their baseline characteristics are summarized in Table 1. The primary diseases requiring surgery were 20 benign diseases, including 14 congenital diseases (54%) and 17 malignant diseases (45.9%). All patients had HJSS, as confirmed by dilation of the entire intrahepatic bile duct on contrast-enhanced computed tomography or magnetic resonance imaging.

EUS-HGS/HJS procedures and related AEs

The results of the initial EUS-HGS/HJS procedure are summarized in Table 2. The technical success rate was 94.6% (35/37). Puncture failed in two patients necessitating PTBD: one because of a non-dilated bile duct and the other because of atrophy of the left hepatic lobe. The median procedure time was 50 (IQR, 37–68) minutes. The B3 branch was selected in 85.7% (30/35) of patients, B2 branch was selected for the remainder. Median diameter of the bile duct that was punctured was 5.2 (IQR, 3.9–6.3) mm. We performed EUS-HGS/HJS with antegrade stenting, bridging the HJSS with a DPPS in 71.4% (25/35) of patients; in 28.6% (10/35), we failed to pass the HJSS in the initial procedures. In one patient, we could not pass the HJSS even after the EUS-HGS site had matured. Clinical success was achieved after EUS-HGS/HJS in all cases (100%). AEs occurred in six (17.1%) patients, including cholangitis (n=3), bile leakage (n=2), and mediastinitis (n=1). Two patients with cholangitis required additional treatment with nasobiliary tube and plastic stent placement. One patient with cholangitis was treated with placement of a fully covered self-expandable metallic stent (FCSEMS) 6 days after EUS-HGS. The mediastinitis and bile leakage improved after conservative treatment. No late AEs were observed.

Clinical course after EUS-HGS/HJS

During the 1-year observation period, 23 benign strictures were observed, with multiple stenting procedures used to bridge the HJSS site, as summarized in Table 3. The success rate of stent removal after multiple stent placements over a 1-year period was 82.6% (n=19/23). Of the 35 patients who underwent successful EUS-HGS/HJS, 4 died within 1 year after multiple stenting procedures (Fig. 2), 3 underwent exchange of the plastic stent for a partially covered self-expandable metallic stent, and 1 was transferred to a different hospital. Four patients did not have their DPPSs removed within 1 year of multiple stenting. The placement of multiple stents was maintained over a 1-year period because the stent did not pass the HJSS in one patient and in three cases, the patient’s desire to keep the stent in place. The 19 patients who underwent stent removal also underwent POCS, as summarized in Table 4. The median time from multiple stenting to POCS insertion was 27 days (IQR, 27-51.5). There were two cases of cholangitis and one case of biliary peritonitis with bile leakage. In both cases, the intraluminal bile duct pressure was elevated due to the EHL procedure with the first POCS insertion. However, all patients were treated conservatively. Eight patients underwent biopsy alone, one underwent EHL alone, eight underwent both, and two underwent neither. The pathological findings were hyperplasia in three cases and inflammation in all other cases. Figure 3 shows a biopsy of the stricture site, and Figure 4 shows the EHL used for the treatment of stones. Patients without biopsy had no macroscopic change at the mucosal membrane of the HJSS. The median duration of stent placement was 456 (IQR, 364–581) days. We have removed the stent within the past 1 year, without stones or strictures. Patients with intrahepatic bile duct stones required more than one year, even if they had stricture resolution. The median follow-up duration after stent removal was 663 (IQR, 621.5–1,287) days. During the follow-up period in 19 patients who had removed DPPSs, three patients (15.8%) developed recurrence of HJSS at a median of 189 (IQR, 172.5–339.5) days after stent removal. One of these patients had symptomatic recurrence in the form of cholangitis, whereas the others had asymptomatic recurrence in the form of intrahepatic stones, as shown by imaging examinations. For the management of recurrent cases, EUS-HGS/HJS was repeated in two patients and PTBD in one. Two patients with cholangitis underwent ERCP for the addition of drainage, one patient with cholangitis required FCSEMS placement, and the others were treated conservatively.

DISCUSSION

This study demonstrated the feasibility of primary EUS-D/A, EUS-HGS/HJS, and trans-ESCR for the treatment of HJSS. The technical and clinical success rates of EUS-D/A are relatively high, and the AE rate is acceptable. However, the diameter of the bile duct was small in some failed cases. The selection of patients and development of new technology for puncturing the non-dilated bile duct should be established. Stricture resolution and recurrence rates were 82% and 15.8%, respectively. HJSS is a major late complication of biliary reconstruction surgery and has historically been treated with PTBD. Currently, HJSS is often treated using BE-ERCP. The reported HJSS resolution rates range from 61% to 90% in PTBD and related procedures¹⁸^,¹⁹ and from 73% to 94% in BE-ERCP procedures.²⁰^,²¹ The HJSS resolution rate in this pilot study was comparable to those reported in previous studies. However, the optimal EUS-HGS/HJS procedure for treating patients with HJSS remains unclear. Primary EUS-D/A is technically feasible and has an acceptable rate of AEs. Additionally, the trans-ESCR procedure facilitates repeated treatment and evaluation after EUS anastomosis maturation.

Stent exchange, including balloon dilation, insertion of a POCS for biopsy, and procedures under POCS observation, are possible through ESCR. Despite the lack of dedicated devices, we were able to perform various trans-ESCR procedures, especially POCS observation, and related procedures such as biopsy and EHL for intrahepatic stones. Determination of benign or malignant diseases is an important initial step. Imaging examinations and observation of the clinical course are useful; however, pathological confirmation is important. POCS insertion during EUS-D/A is feasible and effective but requires a long time to perform because of the need for maturation of the EUS-guided anastomosis. A shorter interval between the initial EUS-HGS/HJS and POCS insertion should be the goal of EUS-D/A, and a transpapillary procedure, POCS, or biopsy can be performed simultaneously with a drainage procedure.

Ogura et al.²² reported a resolution rate of 85.7% for EUS-guided antegrade stenting using an FCSEMS placed at the HJSS. In comparison, using both FCSEMS and single plastic stent, Nagai et al.²³ reported a resolution rate of 50%. Compared with these studies, we used multiple plastic stents and achieved a resolution rate of 83%, which is similar to that using FCSEMS. Regarding stricture recurrence, previous studies reported recurrence rates of 16% and 33%, respectively; our rate was similar to that with FCSEMS and better than that with a single plastic stent. There were no AEs related to stent removal.

Stent selection to improve benign strictures is controversial and is similar to transpapillary stenting. Previous studies also revealed recurrence rates of 8.4% to 34.4% after BE- ERCP.²⁴^-²⁶ FCSEMS are acceptable in interventional EUS strategies, but many clinicians are concerned about the difficulty of stent removal. However, any stent can be selected for the management of HJSS with EUS-D/A and trans-ESCR procedures. Thus, stent selection criteria need to be established.

This study has several limitations. First, this was a single-center, single-arm, retrospective pilot study with a relatively small number of patients. Second, EUS-D/A was performed by experts; therefore, our success rate is likely to be higher than that at a non-tertiary center. Finally, dedicated EUS-D/A devices and prospective studies are required to standardize the procedure.

In conclusion, EUS-D/A and trans-ESCR, including POCS, are feasible and effective for the management of HJSS. The stricture resolution rate in this study was comparable to that of the transpapillary procedures. Evaluation of the HJSS was possible with POCS but required a relatively long time to perform, and dedicated devices for both EUS-D/A and trans-ESCR procedures have not been developed. Further prospective and comparative studies involving transpapillary procedures are warranted to confirm the results of the present pilot study.

Conflicts of Interest

Hiroyuki Isayama, honoraria for lectures from Century Medical, Boston Scientific, Zeon Medical, Gadelius Medical, Fujifilm, Olympus, and research funding from Boston Scientific, Zeon Medical, Gadelius Medical, and Fujifilm. The other authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: HI; Data curation: MU, TF, KT, YT, SI, KI, AS, DN, ST, TF, HO, DK, MI, II, YJ, HH, YY, TO, SA; Formal analysis: MU, TF, KT, YT; Investigation: KT, YT, SI, KI, AS, DN, ST, TF, HO, DK, MI, II, YJ, HH, YY, TO, SA; Methodology: HI, MU; Project administration: MU; Supervision: HI; Validation: MU, TF, KT, YT; Visualization: MU, TF, KT, YT; Writing–original draft: MU; Writing–review & editing: all authors.

Fig. 1.

Treatment strategy. The arrowheads show the stagnation of contrast medium, double plastic stents (PSs), and stricture resolution. EUS-BD, endoscopic ultrasound-biliary drainage; DPPS, double pigtail plastic stent; POCS, peroral cholangioscope; EHL, electrohydraulic lithotripsy; CSEMS, covered self-expandable metallic stent; FCSEMS, fully CSEMS.

Fig. 2.

Flowchart of patient treatment. EUS-BD, endoscopic ultrasound-biliary drainage; HJSS, hepaticojejunostomy stricture.

Fig. 3.

Peroral cholangioscopic examination of hepaticojejunal stricture. (A) Typical benign stricture (arrow) with a penetrating guidewire. Scar tissue was observed around strictures. (B) Mini-biopsy of the hepaticojejunal stricture forceps (SpyBite and SpyBite MAX; Boston Scientific).

Fig. 4.

Intrahepatic bile duct stones (circle) and electrohydraulic lithotripsy probe (EHL AutolithTOUCH; Northgate Technologies).

Table 1.

Patient characteristics

Characteristic	Value (n=37)
Age (yr)	59.5 (35–70)
Sex, male	17 (45.9)
Primary disease for surgery
Congenital biliary dilatation	9 (24.3)
Congenital biliary atresia	5 (13.5)
IPMC	4 (10.8)
Cholecystitis	3 (8.1)
Pancreatic cancer	2 (5.4)
Alcohol cirrhosis	1 (2.7)
Pancreatic cyst	1 (2.7)
Gallbladder cancer	3 (8.1)
IPMA	1 (2.7)
Hepatoblastoma	1 (2.7)
Distal bile duct cancer	2 (5.4)
Hilar cholangiocarcinoma	2 (5.4)
Intrahepatic bile duct cancer	2 (5.4)
Metastasis of colorectal cancer	1 (2.7)
Primary surgery
Pancreaticoduodenectomy	10 (27.0)
Diversion surgery	9 (24.3)
Kasai surgery	5 (13.5)
Extrahepatic bile duct resection+cholecystectomy	6 (16.2)
Hepatectomy	5 (13.5)
Living liver transplantation	2 (5.4)

Values are presented as median (interquartile range) or number (%).

IPMC, intraductal papillary mucinous cancer of the pancreas; IPMA, intraductal papillary mucinous adenoma of the pancreas.

Table 2.

Results of endoscopic ultrasound-guided hepaticogastrostomy/hepaticojejunostomy

Results of Initial EUS-BD	Value (n=37)
Technical success of EUS-BD	35 (94.6)
Clinical success of EUS-BD (n=35)	35 (100.0)
Procedure time of EUS-BD (min)	50 (37–68)
Puncture branch, B3 (n=35)	30 (85.7)
Diameter of the bile duct	5.2 (3.9–6.3)
19-G needle (n=35)	35 (100.0)
Stent location (n=35)
Across the stricture	34 (97.1)
Proximal to the stricture	1 (2.9)
Early adverse events (n=35)	6 (17.1)
Cholangitis	3 (8.6)
Bile leakage	2 (5.7)
Mediastinitis	1 (2.9)

Values are presented as number (%) or median (interquartile range).

Table 3.

One-year observation period with multiple stents

Patients pass over a year with multiple PSs	Value (n=23)
Stricture resolution and stent removal number of stents	19 (82.6)
Double	18 (78.3)
Triple	5 (21.7)
Time to removal from multiple stents (day)	421.5 (364–581)
Follow-up duration after stent remove (day)	935 (631.5–1,287)
Final stent location
Across the stricture	22 (95.7)
Proximal to the stricture	1 (4.3)
Recurrence (n=19)	3 (15.8)
Time to recurrence (day)	189 (172.5–339.5)

Values are presented as number (%) or median (interquartile range).

PS, plastic stent.

Table 4.

Results of the peroral cholangioscopic procedure

Results of POCS	Value (n=19)
Age (yr)	63 (38–70)
Sex, male	8 (42.1)
Time from multiple stenting to POCS insertion (day)	37 (7–52)
Procedure details
Biopsy only	8 (42.1)
EHL only	1 (5.3)
Both EHL and Biopsy	8 (42.1)
Observation only	2 (10.5)
Pathological results	16 (84.2)
Hyperplasia	3 (18.8)
Inflammation	13 (81.3)
Early adverse events	2 (10.5)
Cholangitis	2

Values are presented as median (interquartile range) or number (%).

POCS, peroral cholangioscope; EHL, electrohydraulic lithotripsy.

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Efficacy of primary endoscopic ultrasound-guided biliary drainage with the placement of multiple plastic stents in the management of hepaticojejunostomy stricture: a retrospective, single-center study in Japan

Clin Endosc. 2025;58(6):909-917. Published online November 6, 2025

DOI: https://doi.org/10.5946/ce.2025.006

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Fig. 1. Treatment strategy. The arrowheads show the stagnation of contrast medium, double plastic stents (PSs), and stricture resolution. EUS-BD, endoscopic ultrasound-biliary drainage; DPPS, double pigtail plastic stent; POCS, peroral cholangioscope; EHL, electrohydraulic lithotripsy; CSEMS, covered self-expandable metallic stent; FCSEMS, fully CSEMS.

Fig. 2. Flowchart of patient treatment. EUS-BD, endoscopic ultrasound-biliary drainage; HJSS, hepaticojejunostomy stricture.

Fig. 3. Peroral cholangioscopic examination of hepaticojejunal stricture. (A) Typical benign stricture (arrow) with a penetrating guidewire. Scar tissue was observed around strictures. (B) Mini-biopsy of the hepaticojejunal stricture forceps (SpyBite and SpyBite MAX; Boston Scientific).

Fig. 4. Intrahepatic bile duct stones (circle) and electrohydraulic lithotripsy probe (EHL AutolithTOUCH; Northgate Technologies).

Graphical abstract

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Graphical abstract

Characteristic	Value (n=37)
Age (yr)	59.5 (35–70)
Sex, male	17 (45.9)
Primary disease for surgery
Congenital biliary dilatation	9 (24.3)
Congenital biliary atresia	5 (13.5)
IPMC	4 (10.8)
Cholecystitis	3 (8.1)
Pancreatic cancer	2 (5.4)
Alcohol cirrhosis	1 (2.7)
Pancreatic cyst	1 (2.7)
Gallbladder cancer	3 (8.1)
IPMA	1 (2.7)
Hepatoblastoma	1 (2.7)
Distal bile duct cancer	2 (5.4)
Hilar cholangiocarcinoma	2 (5.4)
Intrahepatic bile duct cancer	2 (5.4)
Metastasis of colorectal cancer	1 (2.7)
Primary surgery
Pancreaticoduodenectomy	10 (27.0)
Diversion surgery	9 (24.3)
Kasai surgery	5 (13.5)
Extrahepatic bile duct resection+cholecystectomy	6 (16.2)
Hepatectomy	5 (13.5)
Living liver transplantation	2 (5.4)

Results of Initial EUS-BD	Value (n=37)
Technical success of EUS-BD	35 (94.6)
Clinical success of EUS-BD (n=35)	35 (100.0)
Procedure time of EUS-BD (min)	50 (37–68)
Puncture branch, B3 (n=35)	30 (85.7)
Diameter of the bile duct	5.2 (3.9–6.3)
19-G needle (n=35)	35 (100.0)
Stent location (n=35)
Across the stricture	34 (97.1)
Proximal to the stricture	1 (2.9)
Early adverse events (n=35)	6 (17.1)
Cholangitis	3 (8.6)
Bile leakage	2 (5.7)
Mediastinitis	1 (2.9)

Patients pass over a year with multiple PSs	Value (n=23)
Stricture resolution and stent removal number of stents	19 (82.6)
Double	18 (78.3)
Triple	5 (21.7)
Time to removal from multiple stents (day)	421.5 (364–581)
Follow-up duration after stent remove (day)	935 (631.5–1,287)
Final stent location
Across the stricture	22 (95.7)
Proximal to the stricture	1 (4.3)
Recurrence (n=19)	3 (15.8)
Time to recurrence (day)	189 (172.5–339.5)

Results of POCS	Value (n=19)
Age (yr)	63 (38–70)
Sex, male	8 (42.1)
Time from multiple stenting to POCS insertion (day)	37 (7–52)
Procedure details
Biopsy only	8 (42.1)
EHL only	1 (5.3)
Both EHL and Biopsy	8 (42.1)
Observation only	2 (10.5)
Pathological results	16 (84.2)
Hyperplasia	3 (18.8)
Inflammation	13 (81.3)
Early adverse events	2 (10.5)
Cholangitis	2

Table 1. Patient characteristics

Values are presented as median (interquartile range) or number (%).

IPMC, intraductal papillary mucinous cancer of the pancreas; IPMA, intraductal papillary mucinous adenoma of the pancreas.

Table 2. Results of endoscopic ultrasound-guided hepaticogastrostomy/hepaticojejunostomy

Values are presented as number (%) or median (interquartile range).

Table 3. One-year observation period with multiple stents

Values are presented as number (%) or median (interquartile range).

PS, plastic stent.

Table 4. Results of the peroral cholangioscopic procedure

Values are presented as median (interquartile range) or number (%).

POCS, peroral cholangioscope; EHL, electrohydraulic lithotripsy.