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Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been used in combination with bridging and antegrade stenting [1] [2]; however, uncovered metal stents often suffer from tumor ingrowth and limited patency [3]. A newly developed multi-hole metal stent with a 5.9-Fr slim delivery system (HANAROSTENT Biliary Multi Hole Benefit; M.I. Tech Co., Ltd, Pyeongtaek, South Korea) has been developed ([Fig. 1] [4] [5]). Herein, we report a novel EUS-HGS technique achieving simultaneous bridging and antegrade stent-in-stent placement using multi-hole metal stents ([Video 1]). A 67-year-old woman was referred to our hospital with hilar biliary obstruction due to advanced gallbladder cancer ([Fig. 2]). Because the duodenum was obstructed, EUS-HGS was selected as the initial drainage approach ([Fig. 3], [Fig. 4]). The intrahepatic bile duct was punctured using a 19-gauge needle, and after contrast injection, a 0.025-inch guidewire was advanced across the stricture into the common bile duct, followed by insertion of a double-lumen catheter. Cholangiography revealed a bismuth type IIIa stricture, and a second guidewire was inserted into the right anterior branch. A slim delivery system for the multi-hole metal stent was smoothly advanced across the hilar stricture into the anterior brunch. The first multi-hole metal stent (6 mm and 6 cm) was deployed as a bridging stent from the right to the left intrahepatic bile duct. The guidewire was then manipulated through a side hole of the first stent toward the common bile duct, and both the side hole and the stricture were dilated using a balloon catheter. A second multi-hole metal stent was inserted as an antegrade stent through the side hole, resulting in successful partial stent-in-stent placement. Finally, a plastic stent was placed through the hepaticogastrostomy tract. To the best of our knowledge, this is the first report of EUS-HGS with simultaneous bridging and antegrade stent-in-stent placement using multi-hole metal stents. This technique may offer prolonged patency for hilar biliary obstruction with duodenal stenosis.
Fig. 1 HANAROSTENT Biliary Multi Hole Benefit (M.I. Tech Co., Ltd, Pyeongtaek, South Korea).
The 5.9-Fr slim delivery system can pass smoothly through the side hole.Download VideoA novel EUS-HGS technique achieving simultaneous bridging and antegrade stent-in-stent
placement using multi-hole metal stents. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy.Video 1
Fig. 2 Computed tomographic images before biliary drainage. a Coronal imaging shows a bismuth type IIIa hilar biliary obstruction caused by advanced
gallbladder cancer. b The duodenum is obstructed by tumor invasion.
Fig. 3 Endoscopic ultrasonography-guided hepaticogastrostomy. a The intrahepatic bile duct is punctured using a 19-gauge needle. b A guidewire is advanced across the stricture, and cholangiography confirms hilar biliary
obstruction. c A second guidewire is inserted into the right anterior branch using a double-lumen
catheter. d The slim delivery system of the first stent is smoothly advanced into the right anterior
branch.
Fig. 4 Bridging and antegrade stent-in-stent placement under EUS-HGS guidance. a After deployment of the first multi-hole metal stent as a bridging stenting, the guidewire
is manipulated through a side hole toward the common bile duct. b The guidewire is advanced across the stricture, followed by 6-mm balloon dilation
of both the side hole and the stricture. c The second multi-hole metal stent is deployed as an antegrade stent through the side
hole of the first stent. d A 7-Fr plastic stent is finally placed through the hepaticogastrostomy tract. EUS-HGS,
endoscopic ultrasound-guided hepaticogastrostomy.
Endoscopy_UCTN_Code_TTT_1AS_2AH
Article published online:
22 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/).
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