AbstractBackground and AimEndoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS) is widely used in the management of biliary obstructions; however, literature on guidewire manipulation is lacking. This study aimed to assess the utility and optimal conditions of the loop technique for guidewire manipulation during EUS‐HGS.MethodsConsecutive patients who underwent EUS‐HGS between April 2015 and January 2022 were included in this study. Patient characteristics and procedural details were retrospectively analyzed. Guidewire manipulations were classified as conventional technique or loop technique, based on the shape of the guidewire tip.ResultsA total of 52 patients (Median age: 73 years, 38 male and 14 female) underwent EUS‐HGS. The median guidewire insertion time was 49 s and the median overall procedure time was 20.5 min. The initial guidewire direction was toward the peripheral side in 23 patients (44%). Technical success rate of the EUS‐HGS was 100%. Twenty patients (38%) underwent the procedure using the loop technique and 32 (62%) with the conventional technique. In the logistic regression analysis, an angle between the bile duct and needle of >70° was independently associated with use of the loop technique (OR 9.84; 95% CI: 2.24–43.13;P<0.01).ConclusionThis study revealed the utility of the loop technique in EUS‐HGS. This technique is recommended if the bile duct is punctured at an angle >70°.