Endoscopic Ultrasound-Guided Biliary Drainage Using a Fully Covered Metallic Stent after Failed Endoscopic Retrograde Cholangiopancreatography

Figure 1

(a) Echoendoscope was advanced into the stomach. After checking local vasculature with color Doppler, the EUS puncture needle was then advanced into the intrahepatic duct. (b) Cholangiography was performed, which usually delineates the dilated biliary tree down to the point of obstruction. (c) A guidewire was then inserted through the needle. (d) The cystotome was used to create a fistula between the stomach and the left hepatic duct. (e) The distance between the stomach and the left hepatic duct was measured. (f)–(i) Once the fistula has been dilated, a fully covered SEMS (10 mm diameter × 8 cm length, fully covered with a silicon membrane) was inserted and deployed transmurally.

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