Cholangioscopy and double guidewires facilitate a difficult endoscopic ultrasound-guided gastroenterostomy

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with electrocautery-enhanced lumen-apposing metal stents (LAMSs) is a promising minimally invasive approach for benign or malignant gastric outlet obstruction (GOO). Guidewire-assisted oroenteric catheters (OECs) or balloon catheters are commonly used to distend the small bowel for puncture. However, failed guidewire passage may complicate the procedure. A 59-year-old woman with GOO after liver transplantation and hilar bile duct plasty was scheduled for EUS-GE. However, multiple endoscopes (ultra-slim endoscope, enteroscope, gastroscope, and colonoscope) failed to reach the pylorus due to severe scope looping, despite abdominal compression and repositioning ([ Fig. 1 ] a ). To overcome this situation, a 9 Fr cholangioscope (IMAX, Nanwei Medical) was advanced through the 3.7 mm channel of a colonoscope, traversed the pylorus, and entered the duodenal bulb ([ Fig. 1 ] b ). The pathway was visualized hidden at a 1 o’clock position in the duodenal bulb ([ Fig. 2 ]). Under direct vision, an angled-tip hydrophilic guidewire (RF*PA35263M, Terumo) was advanced, followed by the cholangioscope into the jejunum ([ Fig. 3 ]). Subsequently, a Boston Scientific Jagwire high-performance guidewire (M00556580) was inserted via an 8.5 Fr bougie catheter to secure dual-wire access ([ Fig. 4 ]). Then, a 7 Fr OEC was used to infuse dye-mixed saline. Finally, a 15-mm Hot AXIOS LAMS (Boston Scientific) was successfully deployed under a linear echoendoscope guidance, with positioning confirmed by endoscopy, EUS, and fluoroscopy ([ Fig. 5 ], [ Video 1 ]). The second guidewire was then withdrawn. The patient resumed a liquid diet 3 days later. Fig. 1 a Schematic illustration showing severe scope looping in a patient with gastric outlet obstruction and surgically altered anatomy after liver transplantation and hilar bile duct plasty, preventing endoscopic passage to the pylorus despite abdominal compression and repositioning. b Schematic illustration of a cholangioscope advanced through the working channel of a colonoscope to traverse the pylorus and enter the duodenal bulb, overcoming the limitation of severe scope looping in surgically altered anatomy. Fig. 2 The hidden pathway to the jejunum located at the 1 o’clock position in the duodenal bulb, obscured by altered gastric anatomy. Fig. 3 An angled-tip hydrophilic guidewire was inserted, navigating a sharply curved duodenal bulb with the maximal bend highlighted by a red circle, and advancing distally into the jejunum. Fig. 4 A fluoroscopic image showing dual-guidewire access established using an 8.5 Fr bougie catheter. Fig. 5 Successful deployment of a LAMS between the stomach and the jejunum under combined guidance of dual-guidewire access and cholangioscopy, with the LAMS position highlighted by a red circle. LAMS, lumen-apposing metal stent. Download Video Cholangioscopy-assisted EUS-GE in a patient with surgically altered anatomy. The video highlights overcoming severe scope looping by cholangioscopy through a colonoscope, precise navigation using angled-tip guidewires under direct vision, establishment of dual-guidewire access for the procedural backup, and safe deployment of a LAMS with real-time confirmation, minimizing fluoroscopy use.Video 1 This case highlights key technical advantages that enabled successful EUS-GE in surgically altered anatomy. First, cholangioscopy within a colonoscope increased rigidity and reach, overcoming severe gastric looping. Second, angled-tip guidewires enabled precise navigation under direct vision by cholangioscopy. Third, real-time visualization allowed the confident identification of the jejunal lumen without contrast or radiation. Finally, dual-guidewire access offered a backup for feeding tube placement and enabled repeat cholangioscopy to confirm LAMS deployment, reducing reliance on fluoroscopy. Endoscopy_UCTN_Code_TTT_1AO_2AN Publication History Article published online: 08 January 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany