Piercing technique for mucosal hyperplasia at an uncovered part of a partially covered stent after endoscopic ultrasound-guided hepaticogastrostomy

A partially covered self-expandable metal stent (PCSEMS) is preferred in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) to prevent stent dislocation and branch duct occlusion [1] [2]. A PCSEMS with a 10-mm uncovered part on the proximal end (Modified Giobor Stent; Taewoong Medical, Seoul) ([Fig. 1]a) has been used frequently [2] [3]; however, tissue hyperplasia occurs around the uncovered part, leading to recurrent biliary obstruction (RBO) [2] [3]. RBO due to hyperplasia is sometimes hardened with abundant fibrosis, resulting in failed guidewire passage during endoscopic reintervention [3] [4]. Here, we present a novel technique to regain biliary access after EUS-HGS with subsequent hyperplasia with the uncovered portion of the PCSEMS.