Endoscopic ultrasonography-guided B3 branch drainage/anastomosis as hepaticoduodenostomy in atrophic left hepatic lobe case

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is widely performed as a salvage procedure when endoscopic retrograde cholangiopancreatography (ERCP) is difficult or has failed [ 1 ] [ 2 ]. EUS-HGS is the most common type of EUS-guided biliary drainage or anastomosis (EUS-BD/A) for the left intrahepatic bile duct (IHBD), which is punctured from the stomach [ 3 ]. In contrast, EUS-guided hepaticoduodenostomy (EUS-HDS) is usually performed by approaching the right IHBD from the duodenum [ 4 ]. However, we report a case of EUS-HDS approaching the left IHBD in a patient with an atrophic left hepatic lobe. A 76-year-old man with distal biliary obstruction due to duodenal cancer was hospitalized ([ Fig. 1 ]). The patient was unfit for surgery because of severe obstructive pulmonary dysfunction, and a 7-Fr straight biliary plastic stent (PS) was placed transpapillary. When the PS became occluded, reapproaching the papilla was unsuccessful because of duodenal obstruction. EUS-HGS was attempted, but the liver could not be visualized from the stomach due to atrophy of the left hepatic lobe. A slightly dilated B3 branch (approximately 2 mm) was visualized from the first portion of the duodenum using a convex-type echoendoscope (EG-740UT, Fujifilm Corp.,Tokyo, Japan) [ 5 ], and puncture was performed with a 19-gauge needle (EZ Shot 3 Plus, Olympus, Tokyo, Japan). After successful puncture and cholangiogram, a 0.025-inch guidewire (VisiGlide2, Olympus, Tokyo, Japan) was inserted. The tract was dilated using a drill (Tornus ES; Asahi Intec, Aichi, Japan) and a 4-mm balloon dilator (REN; Kaneka, Osaka, Japan). Finally, a partially covered self-expandable metallic stent with an antimigration system (8 mm×12 cm Spring Stopper; Taewoong Medical, Seoul, Korea) was deployed ([ Fig. 2 ]; [ Video 1 ]). Post‐procedural computed tomography confirmed appropriate stent placement and no adverse events were observed. Fig. 1 a Computed tomography showing wall thickening of the duodenum and dilation of the common bile duct and intrahepatic bile ducts. b An endoscopic image showing circumferential wall thickening of the descending duodenum. The tumor involves major papilla. Fig. 2 a A fluoroscopic image showing puncture and opacification of the B3 using a 19-gauge needle through the echoendoscope. b A partially covered self‐expandable metallic stent (SEMS) with an antimigration system was deployed between the B3 and the duodenum. c An endoscopic view showing the SEMS in the duodenum with an adequate intraduodenal portion. d A sagittal computed tomography image confirming the appropriate positioning of the metallic stent without bile leakage. Download Video Endoscopic ultrasound-guided drainage/anastomosis of the B3 as hepaticoduodenostomy.Video 1 In standard practice, EUS-HDS targets the right IHBD from the first portion of the duodenum. However, in cases with an atrophic left hepatic lobe, EUS-HDS targeting the left IHBD may also represent a feasible option for EUS-BD/A. Endoscopy_UCTN_Code_TTT_1AS_2AD Publication History Article published online: 28 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