Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a promising treatment option for patients with biliary obstruction.1-3 However, EUS-BD may be associated with serious complications, especially bile leakage which may cause fatal peritonitis.4 Although various techniques have been used for dilation, bile can leak after fistula dilation with any techniques. The duration of the procedure, from dilation to stent deployment, should be reduced, or ideally, eliminated to prevent severe adverse events. To achieve this, we first designed a new technique for covered metal stent deployment using a tapered sheath (EndoSheather; Piolax, Kanagawa, Japan)5 preventing bile leakage. This device allows fistula dilation and subsequent smooth stent delivery through the indwelling outer-sheath, which provides a secure route to cross the fistula without any concern.

An 81-year-old female was admitted with pancreatic ductal adenocarcinoma and obstructive jaundice (Fig. 1). Combined EUS-guided hepaticogastrostomy (EUS-HGS) with antegrade stenting (EUS-AS) was performed. Under EUS guidance, the B3 bile duct was punctured with a 19-gauge needle, and a 0.025-inch guidewire was subsequently advanced into the duodenum in an antegrade fashion. Then, the endoscopic sheath, with a tapered inner-catheter tip, was inserted into the bile duct to dilate the fistula (Fig. 2). After passing this device through the biliary stricture, only the inner-catheter was removed, leaving the outer-sheath inside the bile duct. Finally, an uncovered metal stent (8 × 60 mm) with a 5.7-Fr delivery system (BileRush Selective; Piolax) for EUS-AS and a covered metal stent (8 × 120 mm) with a 5.9-Fr delivery system (HANARO Benefit; Boston Scientific, Marlborough, MA, USA) for EUS-HGS, were deployed through the outer-sheath in sequence (Video S1). In fact, this method might currently restrict the selection of stents for EUS-BD, further improvement of stent devices would be expected to grow availability of this technique.

Imaging findings. (A) Contrast-enhanced computed tomography indicated a poorly enhancing region (yellow arrowhead) with a dilated upstream main pancreatic duct (orange arrow). (B) Magnetic resonance cholangiopancreatography demonstrated a biliary stricture.

A picture of the endoscopic tapered sheath (EndoSheather) and images of the fluoroscopic cholangiogram obtained during endoscopic ultrasound-guided biliary drainage. (A) Tip calibers of the inner-catheter and the outer-sheath have a negligible difference. Less than 0.035-inch of wire is adapted to this inner-catheter. Outer-sheath external diameter, 7.2-Fr (2.44 mm); interior diameter, 6.2-Fr (2.06 mm). The outer-sheath tip has a radiopaque marker (blue arrowhead). (B) Blue arrowhead shows the radiopaque marker of the outer-sheath of the EndoSheather, which allows fistula dilation and subsequent stent delivery through the indwelling outer-sheath without any device exchanges; (C) endoscopic ultrasound-guided hepaticogastrostomy was successfully performed by deploying of covered metal stent through the indwelling sheath, thereby avoiding bile leakage.

The endoscopic tapered sheath, which provides smooth covered metal stent deployment, has great potential to prevent bile leakage during EUS-BD.

Authors declare no conflict of interest for this article.