Multiple Self-Made Side Holes in a Fully Covered Metal Stent Prevent Intrahepatic Bile Duct Occlusion Following Endoscopic Ultrasound-Guided Hepaticogastrostomy: A Retrospective Study in Japan

<b>Background/Objectives</b>: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using a fully covered self-expandable metal stent (FCSEMS) is an alternative to endoscopic retrograde cholangiopancreatography for biliary drainage; however, FCSEMSs may cause intrahepatic bile duct (IHD) obstruction and cholangitis. In this study, we developed an FCSEMS with multiple self-made side holes at its tip and evaluated its safety and efficacy. <b>Methods</b>: This retrospective study included 100 patients who underwent EUS-HGS with FCSEMS placement between April 2022 and October 2023. Fifty patients received a conventional FCSEMS, and 50 received an FCSEMS with multiple self-made side holes. Technical and clinical success, residual contrast in the IHD, recurrent biliary obstruction (RBO), and adverse events (AEs) were then evaluated. The clinical success rates were 98% and 90% for the side hole and conventional FCEMS groups, respectively. The amount of residual contrast in the IHD was lower in the side hole group (0% vs. 12%, <i>p</i> = 0.027). RBO incidence was significantly lower in the side hole group (8% vs. 30%, <i>p</i> < 0.001), with migration as the primary cause in the conventional group. Early AEs, including segmental cholangitis, occurred only in the conventional group. During reintervention, all stents were safely removed. <b>Conclusions</b>: The FCSEMSs with multiple side holes reduced IHD occlusion and cholangitis, improving biliary drainage and safety. Further studies are needed to confirm these findings.