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

Sep 30, 2026

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using electrocautery-enhanced lumen-apposing metal stents (LAMSs) offers a minimally invasive option for gastric outlet obstruction, but failed guidewire passage can hinder the procedure. In a 59-year-old woman with surgically altered anatomy after liver transplantation and hilar bile duct plasty, severe scope looping prevented reaching the pylorus. Cholangioscopy via a colonoscope, angled-tip guidewires, and dual-guidewire access enabled real-time identification and safe LAMS deployment with reduced fluoroscopy reliance.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

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Case presentation

Procedure steps and guidance

Outcomes and clinical follow-up

Article published online: 2026-01-08 Cholangioscopy and double guidewires facilitate a difficult endoscopic ultrasound-guided gastroenterostomy Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with electrocauteryenhanced lumen-apposing metal stents (LAMSs) is a promising minimally invasive approach for benign or malignant gastric outlet obstruction (GOO) . Guidewireassisted oroenteric catheters (OECs) or balloon catheters are commonly used to distend the small bowel for puncture. However, failed guidewire passage may complicate the procedure. A59-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.1a) . To overcome this situation, a 9Fr cholangioscope (IMAX, Nanwei Medical) was advanced through the 3.7mm channel of a colonoscope, traversed the pylorus, and entered the duodenal bulb ( ▶ Fig.1b) . 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 8.5Fr bougie catheter to secure dual-wire access ( ▶ Fig.4) . Then, a 7Fr 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. This case highlights key technical advantages that enabled successful EUS-GE in surgically altered anatomy. First, cholangioscopy within a colonoscope increased a b ▶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. 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 ▶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. 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 E32 Liu Jiahuan et al. Cholangioscopy and double… Endoscopy 2026; 58: E32–E33 | © 2026. The Author(s) . ▶Fig.4 A fluoroscopic image showing dual-guidewire access established using an 8.5Fr bougie catheter. Video 1 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. Contributors ʼ Statement | Jiahuan Liu: Data

FAQs

Why was EUS-GE difficult in this case?

Severe scope looping and multiple unsuccessful endoscopes prevented passage to the pylorus in a patient with surgically altered anatomy.

How did cholangioscopy through a colonoscope help?

A 9Fr cholangioscope advanced through the colonoscope channel traversed the pylorus and entered the duodenal bulb, revealing a hidden pathway to the jejunum.

What role did dual-guidewire access play?

Using guidewire-assisted access provided a procedural backup for feeding tube placement and allowed repeat cholangioscopy to confirm LAMS deployment, reducing reliance on fluoroscopy.

Sep 30, 2026

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