Fig. 1. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) using a dedicated partially covered self-expandable metal stent (PCSEMS) (hybrid metal stents; Standard Sci Tech Inc., Seoul, Korea) for obstruction of the left intrahepatic duct (IHD) in malignant hilar biliary obstruction. (A) After failed endoscopic retrograde cholangiopancreatography, EUS-HGS was performed in patients with left intrahepatic obstruction. On EUS, a dilated left IHD was observed on the expected needle track. (B, C) The left IHD (B3) was punctured by a 19-gauge standard needle. (D) The guidewire was delivered up to the main left IHD. (E) The fistula tract was dilated using a 4-mm balloon catheter. (F) A PCSEMS with anchoring flaps was placed through hepaticogastrostomy. Fluoroscopic image showing the stent placed between the stomach and the left IHD.
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