Endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography using antegrade hepaticogastrostomy-assisted saline instillation in Roux-en-Y anatomy: A case report.

Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (EDEE) has become a valuable therapeutic option in patients with non-gastric bypass anatomy requiring biliary access. However, adequate afferent loop access can be challenging. Our aim was to illustrate an alternative way of achieving small bowel distention during EDEE in a patient suffering from recurrent cholangitis due to strictures of both the left and right-sided bilioenteric anastomosis. We employed a temporary EUS-guided hepaticogastrostomy to provide antegrade afferent loop access, facilitating on-demand saline instillation and small bowel distention. Antegrade catheter-based saline instillation provided adequate afferent loop distention and stabilization for the creation of a entero-enteric anastomosis with a lumen-apposing metal stent (LAMS). This allowed for adequate through-the-LAMS endoscopic retrograde cholangiopancreatography (ERCP) and stricture management in non-gastric bypass Roux-en-Y anatomy. We concluded that antegrade hepaticogastrostomy-assisted saline instillation might be useful in patients undergoing EDEE where classic approaches to afferent loop distention have failed.