Endoscopic Transpapillary Research Articles

Endoscopic Gallbladder Drainage Conversion versus Conservative Treatment Following Percutaneous Gallbladder Drainage in High-Risk Surgical Patients.

There are no consensus guidelines for patients with acute cholecystitis undergoing percutaneous cholecystostomy who are unfit for interval cholecystectomy. The current study aimed to compare the clinical outcomes of endoscopic gallbladder drainage, i.e. conversion from percutaneous cholecystostomy (including endoscopic transpapillary gallbladder stenting and endoscopic ultrasound-guided gallbladder drainage), and conservative treatment after percutaneous cholecystostomy tube removal. This retrospective review included patients who underwent percutaneous cholecystostomy for acute cholecystitis between January 2017 and December 2020. Consecutive patients who underwent endoscopic gallbladder drainage or percutaneous cholecystostomy tube removal without interval cholecystectomy were included. Outcome measures included recurrent acute cholecystitis and unplanned readmission due to gallstone-related diseases. During the study period, 238 patients were selected (63 underwent endoscopic gallbladder drainage conversion and 175 underwent conservative treatment). Patients who underwent endoscopic gallbladder drainage conversion had lower rates of recurrent acute cholecystitis (3 [4.76%] vs 31 [17.71%], p=0.012) and unplanned readmission due to gallstone-related diseases (6 [9.52%] vs 40 [22.86%], p=0.022) than those who underwent conservative treatment following percutaneous cholecystostomy tube removal. In the univariate and multivariate analyses, calculus cholecystitis (odds ratio, 13.75; 95% confidence interval, 1.83 to 102.83; p=0.011) and conversion of endoscopic gallbladder drainage (odds ratio, 0.23; 95% confidence interval, 0.06 to 0.78; p=0.019) were significant predictive factors for recurrent acute cholecystitis. Endoscopic gallbladder drainage conversion led to more favorable outcomes than conservative treatment after percutaneous cholecystostomy tube removal. Therefore, endoscopic gallbladder drainage conversion may be considered a promising treatment option for patients undergoing percutaneous cholecystostomy who are at a high surgical risk.

Endoscopic internalization by cutting versus removal of the endoscopic transpapillary naso-gallbladder drainage tube in preoperative management of acute cholecystitis: A retrospective multicenter cohort study.

Endoscopic transpapillary naso-gallbladder drainage (ENGBD) has been reported to be an effective treatment option for acute cholecystitis. At our institution, ENGBD was first placed for external fistula management, and endoscopic internalization by cutting was performed, shifting to endoscopic transpapillary gallbladder stenting (EGBS) after improvement of cholecystitis. However, there has been no comparative study to define which preoperative management is better: converting ENGBD to EGBS or removing ENGBD. The study aimed to compare the incidence rate of the late adverse events (AEs) related to biliary system between shifting from ENGBD to EGBS and removal of ENGBD. We retrospectively studied 122 patients who underwent ENGBD for acute cholecystitis between January 2010 and October 2022. The patients were divided into two groups: the cutting group (converting ENGBD to EGBS) and the removal group (removal of ENGBD). The short and late clinical outcomes were compared between groups. Endoscopic transpapillary naso-gallbladder drainage was successfully placed in 78.6% (96/122), and elective cholecystectomy was performed in 31 and 36 patients in the cutting and removal groups, respectively. The cumulative late-AE rates were 6.4% and 33.3% (p = .007), with a median waiting period for elective cholecystectomy of 58 and 33 days (p = .390) in the cutting and removal groups, respectively. In the multivariate analysis, only endoscopic internalization by cutting was an independent factor affecting late AEs. Endoscopic internalization by cutting ENGBD after the resolution of acute cholecystitis was considered effective in reducing the risk of late AEs during the waiting period for an elective cholecystectomy.

Effect of pancreatic necrosis configuration on the dynamics of external pancreatic fistulas after acute pancreatitis

Aim . To study the effect of the pancreatic necrosis configuration on the course and outcome of external pancreatic fistulas formed at the stage of acute pancreatitis. Materials and methods . The authors studied the dynamics of external pancreatic fistulas existing from 2 to 143 months after invasive interventions for pancreonecrosis in 53 patients. Pancreonecrosis, its depth and configuration were diagnosed by means of CT scan. Results. Pancreatic fistula closed in 30 out of 53 patients: all 10 patients with type 1 configuration in shallow (<50%) necrosis and all 5 patients with type 2 configuration, even in complete transverse necrosis. With deep necrosis of type 1, fistula closed in 15 out of 38 patients. The outflow of juice from the viable parenchyma distal to the necrosis was restored in 7 out of 15 patients. The process was performed by endoscopic recanalization of the duct through the necrotic zone at the stage of acute pancreatitis. The volume of parenchyma distal to the necrosis did not change in the follow-up period: 50.4 ± 19.9 cm 3 and 40.7 ± 14.4 cm 3 ( p > 0.05). In 8 patients, the volume of functioning parenchyma distal to necrosis reduced from 20 ± 6.3 cm 3 to 7.4 ± 2.7 cm 3 ( p < 0.001). In persistent pancreatic fistulas, 23 patients underwent resection and drainage interventions. Conclusion . The type and depth of necrosis configuration, as well as the volume of functioning parenchyma distal to the necrotic zone should be considered to predict the dynamics of pancreatic fistula after pancreatic necrosis. Deep necrosis of the pancreatic parenchyma with type 1 configuration and large volume of viable parenchyma distal to the necrosis suggest a persistent pancreatic fistula. Endoscopic transpapillary recanalization of the pancreatic duct through the zone of deep necrosis at the stage of acute pancreatitis contributes to the closure of the pancreatic fistula and prevents long-term atrophy of distal and functioning pancreatic parenchyma. Shallow necrosis in type 1 configuration and necrosis in type 2 configuration in acute pancreatitis suggest rapid closure of the pancreatic fistula.

Endoscopic Transpapillary Stenting for Malignant Hilar Biliary Stricture: Side-by-Side Placement versus Partial Stent-in-Stent Placement.

Endoscopic uncovered metal stent (UMS) placement has been widely performed for unresectable hilar malignant biliary stricture (UHMBS). Two stenting methods are used for the two bile duct branches: side-by-side placement (SBS) and partial stent-in-stent placement (PSIS). However, it remains controversial whether SBS or PSIS is superior. This study aimed to compare SBS and PSIS in UHMBS cases with UMS placement in two branches of the IHD. This retrospective study included 89 cases of UHMBS treated with UMS placement through the SBS or PSIS technique using endoscopic retrograde cholangiopancreatography at our institution. Patients were divided into two groups, SBS (n = 64) and PSIS (n = 25), and compared. Clinical success was achieved in 79.7% and 80.0% in the SBS and PSIS groups, respectively (p = 0.97). The adverse event rate was 20.3% and 12.0% in the SBS and PSIS groups, respectively (p = 0.36). The recurrent biliary obstruction (RBO) rate was 32.8% and 28.0% in the SBS and PSIS groups, respectively (p = 0.66). The median cumulative time to RBO was 224 and 178 days in the SBS and PSIS groups, respectively (p = 0.52). The median procedure time was 43 and 62 min in the SBS and PSIS groups, respectively, which was significantly longer in the PSIS group (p = 0.014). No significant differences were noted in the clinical success rate, adverse event rate, time to RBO, or overall survival between the SBS and PSIS groups, other than the significantly longer procedure time in the PSIS group.

Improvement of methods of diagnosis and treatment of patients with obstructive jaundice of tumor genesis

The Objective was to improve medical and diagnostic care for patients with obstructive jaundice of tumor genesis.Methods and Materials. Retrospective analysis of the treatment results of 309 patients with obstructive jaundice of tumor genesis. We studied the results of endoscopic transpapillary and/or percutaneous transhepatic antegrade endobilliary minimally invasive surgical interventions of 307 (99.3 %) patients. We carried out the analysis of complications, reasons and possible elimination path. A new, more effective method of trepan-biopsy of tumors of the pancreatic head and distal choledochus and devise for it implementation were developed (patent № 2722655, 2747591).Results. Minimally invasive decompression interventions at the first stage of treatment of patients with obstructive jaundice of tumor genesis reduced the percentage of fatal postoperative complications to 1.3 %. The first results of the application of the developed trepan-biopsy method showed their high efficiency, reliability and safety.Conclusion. The differentiated approach to the choice of the method of decompression of the biliary tract at the first stage is important for improving the results of treatment. The use of the method of simultaneous puncture transhepatic billioduadenal drainage with trepan-biopsy of tumors of the pancreatic head and distal choledochus is, as it seems to us, a new, promising adjustment in solving the problem of morphological verification of tumors of the hepatopancreatoduodenal zone and reducing the time of diagnosis and treatment of patients with obstructive jaundice of the tumor genesis.

Author commentary on Wiriyaporn Ridtitid et al.

Wiriyaporn Ridtitid et al. Intermediate- to long-term outcomes of endoscopic transpapillary gallbladder stenting in patients with gallstone-related disease: a 10-year single-center experience

Ways to prevent acute postmanipulatory pancreatitis in endoscopic transpapillary interventions in patients with mechanical jaundice

To evaluate the effectiveness of preventive measures in relation to the development of acute postmanipulatory pancreatitis in patients after endoscopic transpapillary interventions. Materials and methods: In the period from September 2021 to June 2022, 73 endoscopic transpapillary interventions for benign pathology and malignant pathology were performed in patients. The analysis of the frequency of the development of acute postmanipulatory pancreatitis in different time intervals in patients who underwent prophylaxis in various ways, depending on the combination of risk factors. Results and discussion: Acute postmanipulatory pancreatitis developed in 2 (3.7 %) patients who underwent transpapillary interventions in various volumes for complicated cholelithiasis. Drug prophylaxis of acute postmanipulatory pancreatitis was carried out in the preoperative period for all patients. Preventive stenting of the main pancreatic duct was performed in the presence of a combination of risk factors. Conclusion: The analysis of the results of endoscopic transpapillary interventions made it possible to identify the most significant measures that allowed to reduce the number of developed to 3 acute postmanipulatory pancreatitis to 3.7 % and thereby increase the safety of transpapillary interventions.

Comparison of the long-term outcomes of EUS-guided gallbladder drainage and endoscopic transpapillary gallbladder drainage for calculous cholecystitis in poor surgical candidates: a multicenter propensity score–matched analysis

Although long-term stent placement using endoscopic transpapillary gallbladder drainage (ETGBD) and EUS-guided gallbladder drainage (EUS-GBD) reportedly reduces cholecystitis recurrence, comparative evidence of their safety and efficacy is scarce. This study aimed to examine and compare the long-term utility of EUS-GBD versus that of ETGBD in poor surgical candidates. A total of 379 high-risk surgical patients with acute calculous cholecystitis met the eligibility criteria for enrollment in this study. The technical success and adverse events (AEs) were compared between the EUS-GBD and ETGBD groups, and propensity score matching was performed to adjust for differences between the groups. Both groups underwent plastic stent placement, and scheduled stent exchange and removal were not performed in either group. The technical success rate of EUS-GBD was significantly higher than that of ETGBD (96.7% vs 78.9%, P< .001), whereas the early AE rate did not differ significantly between the 2 methods (7.8% vs 8.9%, P= 1.000). The rate of recurrent cholecystitis did not differ significantly (3.8% vs 3.0%, P= 1.000), but the rate of symptomatic late AEs, in addition to cholecystitis, was significantly lower with EUS-GBD than with ETGBD (1.3% vs 13.4%, P= .006). Consequently, the overall late AE rate was significantly lower with EUS-GBD (5.0% vs 16.4%, P= .029). Multivariate analysis revealed that EUS-GBD was associated with a significantly longer time to late AE (hazard ratio, .26; 95% confidence interval, .10-.67; P= .005). Long-term stent placement via EUS-GBD is a promising potential option for limiting late AEs, including recurrence, in poor surgical candidates with calculous cholecystitis.

Endoscopic transpapillary gallbladder drainage with "hooking technique" using a rotatable sphincterotome.

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Endoscopic Ultrasound-guided Trans-esophageal Transmural Drainage of Mediastinal Pseudocysts: A Case Series

Mediastinal pseudocysts (MP) are rare, and surgery is the conventional treatment modality. However, in the last decade, excellent outcomes have been reported with endoscopic transpapillary drainage. Endoscopic ultrasound (EUS) guided trans-esophageal transmural drainage of MP is a minimally invasive and effective non-surgical treatment modality, but the experience is limited. We aimed to report our experience of EUS-guided transmural drainage in 10 patients with MP's. A retrospective analysis of patients with pancreatic fluid collections treated with EUS-guided transmural drainage over the last ten years was completed to to identify patients with MP's. Ten patients (8 males, with a mean age of 34.9±9.17 years) with MP treated with EUS-guided transesophageal transmural drainage were identified. Nine patients with MP had concurrent chronic pancreatitis, and only one had MP following acute necrotizing pancreatitis. The mean size of MP was 5.70±1.64 cm, and nine patients (90%) had concurrent abdominal pseudocyst. EUS-guided transesophageal transmural drainage was technically successful in all ten patients. Transmural plastic stents were placed in 9 patients, whereas one patient underwent single-time complete aspiration of the MP. There were no immediate or delayed procedure-related complications. All ten patients had a successful outcome, with the mean resolution time being 2.80±0.79 weeks. There has been no recurrence of PFC or symptoms in nine (90%) successfully treated patients over a mean follow-up period of 43.3 months. EUS-guided trans-esophageal drainage of MP is safe with a high technical and clinical success rate.

A novel technique of endoscopic introducer-assisted transpapillary gallbladder aspiration prior to drainage in a patient with acute cholecystitis.

Endoscopic transpapillary gallbladder drainage (ET-GBD) is the preferred technique in patients with acute cholecystitis and cholangitis [1]. Meta-analyses have reported technical and clinical success rates of 83 % and 88.1 % respectively [1] [2]. Aspiration of the infected bile and saline irrigation using nasobiliary drainage is an acceptable method [1]; however, the performance of this maneuver during ET-GBD is time-consuming because of the high viscosity of the bile and the small caliber of the conventional endoscopic retrograde cholangiopancreatography catheter. Endoscopic introducer-assisted procedures have recently emerged as effective pancreaticobiliary interventions [3] [4]. This article describes gallbladder aspiration and irrigation using a novel dual-structure catheter.

Comparison of the hybrid and partial stent-in-stent method for endoscopic three-segment drainage for unresectable malignant hilar biliary obstruction.

Background and study aims The clinical outcome of the new hybrid drainage method for unresectable malignant hilar biliary obstruction (UMHBO) has not yet been compared with that of the partial stent-in-stent (PSIS) method with three or more stents. Patients and methods Patients with UMHBO underwent drainage of three segments using the hybrid or PSIS method. The clinical outcomes of both methods were compared retrospectively. Results Overall, 54 patients underwent the hybrid (n = 31) or PSIS (n = 23) method of drainage with three or more stents for UMHBO. There were no significant differences in the technical success rate (hybrid vs. PSIS, 87.1 % vs. 87 %), clinical success rate according to per-protocol analysis (81.5 % vs. 70 %), early adverse events rate (14.8 % vs. 10%), late adverse events rate (7.4 % vs. 0 %), and technical success rate of the endoscopic transpapillary reintervention (90.9 % vs. 100 %). Time to recurrent biliary obstruction (TRBO) of the hybrid and PSIS methods was 178 and 231 days, respectively, with no significant difference ( P = 0.354). Conclusions The choice between the two methods should be made at the physician's discretion.

Ruptured cystic artery pseudoaneurysm after long-term transpapillary placement of a gallbladder stent for acute cholecystitis.

Endoscopic transpapillary gallbladder drainage (ETGBD), including endoscopic gallbladder stenting (EGBS), has utility in the management of acute cholecystitis in patients considered to be high risk candidates for surgery [1]. A recent meta-analysis reported that the pooled rate of cholecystitis recurrence was 4.6 % following ETGBD in patients with acute cholecystitis [2]. Long-term biliary drainage via EGBS is often performed to prevent the recurrence of cholecystitis in patients with contraindications to cholecystectomy.

Theoretical step approach with 'Three-pillar' device assistance for successful endoscopic transpapillary gallbladder drainage.

Endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis but remains a challenging procedure. To elucidate the efficacy of a strategic approach for ETGBD that utilizes a four-step classification system and the optional use of 'Three-pillar' assistance with the following devices: cholangioscopy (SpyGlass DS, SG), a flex-type guidewire (Flex-GW), and a 3-Fr microcatheter (3-Fr Micro). A total of 115 patients undergoing ETGBD were studied retrospectively. Characteristics and technical outcomes were compared between conventional ETGBD technique (Classical ETGBD, N = 50) and strategic ETGBD with optional Three-pillar assistance (Strategic ETGBD, N = 65). SG-assistance (15/65, 23.1%) was as an excellent troubleshooter in Category 1 (failure to identify the cystic duct [CD] orifice) and Category 2 (failure to advance the GW across the CD takeoff due to unfavorable angle). Flex-GW (19/65, 29.2%) worked for Category 3b (failure of GW access to the GB due to multiple tortuosities). 3-Fr Micro (11/65, 16.9%) was effective for Category 3a (failure of GW access to the GB due to CD obstruction) and Category 4 (failure of drainage stent insertion to the GB). The overall technical success rate was significantly higher for Strategic ETGBD (63/65, 96.9%) compared with Classical ETGBD (36/50, 72.0%) (p = 0.0001). Strategic ETGBD, which includes the Three-pillar assistance options of SG in the initial steps, Flex-GW for tortuous CD, and 3-Fr Micro for stenotic CD, achieved a significantly higher success rate than for Classical ETGBD.

The role of endoscopic draining in the treatment of mechanical jaundice of different etiology on the background of chronic opistorchiasis

Purpose of the study: to conduct a comparative analysis of endoscopic retrograde transpapillary interventions in patients with chronic opisthorchiasis and obstructive jaundice of various etiologies.Material and Methods. The results of treatment of 129 patients with chronic opisthorchiasis and obstructive jaundice of various etiologies who underwent transpapillary interventions to correct bile duct, were analyzed. In order to assess the condition of patients, general clinical methods and a set of laboratory and instrumental methods were used. The study was carried out in two groups, in the first endoscopic drainage of the bile ducts was carried out, in the second – either endoscopic papillosphincterotomy with choledocholitholite extraction, or endoscopic papillosphincterotomy with bougienage of the ducts. Each group of patients was divided into subgroups according to nosology: 1 – diseases of the biliary tract; 2 – oncological diseases of the hepatopancreatic zone; 3 – pancreatitis. Laboratory indicators before and after the application of minimally invasive interventions were compared.Results. The use of various methods of transpapillary interventions normalizes indicators of bilirubin, and aminotransferases in patients by 5–10 days. Endoscopic stenting of the ducts was the method of choice with cancers of the parasitic organs. With concomitant choledocholithiasis, the endoscopic papillosphincterotomy technique with subsequent lithotripsy and lithoextraction were used. Draining operations showed a good efficacy in the treatment of jaundice in the case of impossibility of removing the calculus. Endoscopic papillosphincterotomy with ductal bougienage was the operation of choice for streak tours of the common bile duct. With purulent cholangitis, endoscopic papillotomy with the installation of nasobiliary drainage and subsequent sanitation of the bile ducts was used.Conclusion. The use of endoscopic drainage has proven itself well in patients with obstructive jaundice of tumor etiology, as well as in patients with choledocholithiasis when it is impossible to remove the calculus. This surgery allows for quick normalization of the bilirubin level.

Endoscopic transpapillary repositioning of a migrated cystic duct tube using a gooseneck snare technique.

A cystic duct tube (C-tube) may be inserted via the cystic duct into the common bile duct (CBD) during cholecystectomy for postoperative percutaneous biliary drainage [1] [2] [3] [4] [5]. Postoperative C-tube migration has been reported in 6.6 % cases [2]. Herein, we describe successful endoscopic repositioning of a migrated C-tube ([Video 1]).

Introducer-assisted endoscopic transpapillary gallbladder biopsy for indeterminate gallbladder fundal wall thickness.

Endoscopic transpapillary gallbladder biopsy (ET-GBBx) remains challenging; therefore, there is no recommendation for the histological examination of patients with resectable gallbladder cancer [1] [2]. Endoscopic introducer-assisted procedures recently emerged for pancreatico-biliary interventions [3]. This article describes the use of introducer-assisted ET-GBBx for indeterminate gallbladder fundal wall thickening.

Intermediate- to long-term outcomes of endoscopic transpapillary gallbladder stenting in patients with gallstone-related disease: a 10-year single-center experience.

Endoscopic transpapillary gallbladder stenting (ETGS) can be a bridging therapy to elective cholecystectomy or a permanent gallbladder drainage method in patients with symptomatic gallbladder disease who are awaiting cholecystectomy or are unfit for surgery, respectively. We evaluated the intermediate- to long-term outcomes of ETGS in these groups. We retrospectively reviewed 234 patients (acute cholecystitis = 147), who were unfit for surgery (n = 50) or had deferred cholecystectomy (n = 184) and who underwent ETGS between 2012 and 2021. A 7-Fr, 15-cm, double-pigtail plastic stent was placed for ETGS without scheduled stent exchange. Biliary event-free rates (i. e. cholecystitis and cholangitis) were determined at 6 months, 1 year, and ≥ 2 years. Technical and clinical success rates were 84.6 % (198/234) and 97.4 % (193/198), respectively. Kaplan-Meier analysis (n = 193) showed a biliary event-free rate of 99 % (95 %CI 0.95-1.00) at 6 months, 92 % (95 %CI 0.87-0.97) at 1 year, and 76 % (95 %CI 0.65-0.93) at ≥ 2 years, during a median follow-up period of 564 days (range 200-3001 days). ETGS is an effective biliary drainage method that should be considered in selected cases with common bile duct stone where cholecystectomy could not be performed or was deferred. The biliary event-free rates of ≥ 76 % up to ≥ 2 years further support the use of ETGS in these patient groups.

Endoscopic ultrasonography and transpapillary interventions in the therapeutic and diagnostic algorithm in patients with parapapillary duodenal diverticulum

Endoscopic ultrasonography and transpapillary interventions in the therapeutic and diagnostic algorithm in patients with parapapillary duodenal diverticulum

EUS-guided hepaticogastrostomy of a difficult-to-access biliary obstruction involving the caudate lobe (with video).

EUS-guided hepaticogastrostomy (EUS-HGS) has been increasingly used as an alternative approach to percutaneous biliary drainage after failed transpapillary drainage.[1,2] EUS-HGS is often performed via the B2 or B3 bile ducts due to the proximity of these biliary branches with the stomach. The B1 bile duct at the caudate lobe is considered one of the difficult-to-access bile ducts for percutaneous biliary drainage given its distance from the skin surface. EUS is advantageous in accessing the B1 bile duct given its proximity to the stomach;[3-5] however, to the best of our knowledge, no studies have reported performing EUS-HGS via the B1 bile duct. Herein, we report a case where biliary obstruction involving the B1 bile duct was successfully managed via EUS-HGS. A 97-year-old woman was referred to our hospital for fever and abdominal pain. She had a history of recurrent cholangitis due to benign sclerosing cholangitis. Magnetic resonance imaging (MRI) revealed intrahepatic bile duct dilation in the caudate lobe [Figure 1]. Initially, endoscopic transpapillary drainage was attempted; however, due to severe stricture, the B1 bile duct was not visualized by the cholangiogram. Subsequently, EUS-HGS was planned. Clockwise rotation of the echoendoscope after identification of the lateral liver lobe from the stomach enabled the clear visualization of the B1 bile duct [Figure 2]. The dilated B1 bile duct was punctured using a 19-gauge aspiration needle [Figure 3], and the puncture tract was dilated using a bougie dilator. A dedicated 7-Fr × 14-cm plastic stent (TYPE-IT Stent; Gadelius Medical, Tokyo, Japan) was deployed between the B1 bile duct and stomach [Figure 4 and Video 1]. The patient’s condition improved within a few days, and MRI performed after the procedure revealed a well-drained B1 bile duct [Figure 5]. Currently, cholangitis has not recurred over 6 months after the procedure.Figure 1: Magnetic resonance imaging showing biliary dilation of the B1 bile duct localized at the caudate lobe (arrowheads)Figure 2: EUS shows the B1 bile duct via the gastric wall by clockwise rotation of the echoendoscope after identification of the lateral liver lobe (arrowheads)Figure 3: EUS-guided hepaticogastrostomy for the B1 bile duct. The dilated B1 bile duct was punctured with a 19-gauge aspiration needle. (a) EUS image; (b) fluoroscopic imageFigure 4: A dedicated 7-Fr × 14-cm plastic stent (TYPE-IT Stent; Gadelius Medical, Tokyo, Japan) was successfully deployed between the B1 bile duct and stomach. (a) Endoscopic image; (b) fluoroscopic imageFigure 5: MRI showing a well-drained B1 bile duct. MRI (a) before and (b) after drainage. MRI: Magnetic resonance imaging {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_x2u5iac6"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} This case highlighted the usefulness of an alternative EUS approach to the B1 bile duct, which is generally difficult to approach percutaneously. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.