Endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography using antegrade hepaticogastrostomy-assisted saline instillation in Roux-en-Y anatomy: a case report.

Endoscopic ultrasound (EUS)-directed transenteric endoscopic retrograde cholangiopancreatography (EDEE) has become a valuable therapeutic option in patients with nongastric bypass anatomy requiring biliary access. However, adequate afferent loop access can be challenging. Our aim was to illustrate an alternative way of achieving small-bowel distention during EDEE in a patient with recurrent cholangitis due to strictures of both the left- and right-sided bilioenteric anastomosis. We used a temporary EUS-guided hepaticogastrostomy to provide antegrade afferent loop access, facilitating on-demand saline instillation and small-bowel distention. Antegrade catheter-based saline instillation provided adequate afferent loop distention and stabilization for the creation of an enteroenteric anastomosis with a lumen-apposing metal stent (LAMS). This allowed for adequate through-the-LAMS endoscopic retrograde cholangiopancreatography and stricture management in nongastric bypass Roux-en-Y anatomy. We concluded that antegrade hepaticogastrostomy-assisted saline instillation might be useful in patients undergoing EDEE where classic approaches to afferent loop distention have failed.