biliary obstruction is preferentially managed by endoscopic retrograde cholangiopancreatography ( ercp ) . however , after ercp failed , alternatives include percutaneous transhepatic drainage , surgery and more recently , endoscopic ultrasonography ( eus)-guided hepaticogastrostomy .
the limitation of this technique is that the drainage is restricted to the left side .
the aim of this study is to describe a new method of drainage of both hepatic ductal systems by hepaticogastrostomy in patients with hilar obstruction .
  nine prospectively patients were included , all with hilar obstruction ( metastasis of a pancreatic adenocarcinoma n = 4 , cholangiocarcinoma n = 1 , gallbladder cancer n = 2 and metastasis from a pancreatic neuroendocrine tumor n = 2 ) .
a total of four patients had previously whipple surgery and the others five had duodenal involvement by the tumor .
the topography of the stenosis varied from bismuth type 2 ( n = 7 ) and hilar infiltration in the others two .
the first one consisted in a transgastric eus - guided puncture of the left - side bile duct with a 19 gauge needle , insertion of a 0.0035 inch guide wire which was positioned at the right biliary tree crossing the bile bifurcation . after a dilatation with 6 fr cystotome ,
a non - covered self - expandable metal stent was placed communicating the right and left biliary ducts .
finally , a second stent , partially covered , was inserted at the left biliary duct , with the distal part inside the previously stent and the proximal edge positioned at the stomach .
successful drainage was observed in seven patients , two of them presented abdominal pain during the first 72 h. one patient developed sepsis and death 7 days after the procedure and the other one had drainage failure .
this pilot study shows the feasibility of this new technique to drain the right biliary duct in patients with hilar obstruction , with few major complications rates .
 introduction : biliary obstruction is preferentially managed by endoscopic retrograde cholangiopancreatography ( ercp ) . 
 however , after ercp failed , alternatives include percutaneous transhepatic drainage , surgery and more recently , endoscopic ultrasonography ( eus)-guided hepaticogastrostomy . 
 the limitation of this technique is that the drainage is restricted to the left side . 
 the aim of this study is to describe a new method of drainage of both hepatic ductal systems by hepaticogastrostomy in patients with hilar obstruction.results : nine prospectively patients were included , all with hilar obstruction ( metastasis of a pancreatic adenocarcinoma n = 4 , cholangiocarcinoma n = 1 , gallbladder cancer n = 2 and metastasis from a pancreatic neuroendocrine tumor n = 2 ) . 
 a total of four patients had previously whipple surgery and the others five had duodenal involvement by the tumor . 
 the topography of the stenosis varied from bismuth type 2 ( n = 7 ) and hilar infiltration in the others two . 
 all of them were submitted a three - step drainage . 
 the first one consisted in a transgastric eus - guided puncture of the left - side bile duct with a 19 gauge needle , insertion of a 0.0035 inch guide wire which was positioned at the right biliary tree crossing the bile bifurcation . after a dilatation with 6 fr cystotome , 
 a non - covered self - expandable metal stent was placed communicating the right and left biliary ducts . 
 finally , a second stent , partially covered , was inserted at the left biliary duct , with the distal part inside the previously stent and the proximal edge positioned at the stomach . 
 successful drainage was observed in seven patients , two of them presented abdominal pain during the first 72 h. one patient developed sepsis and death 7 days after the procedure and the other one had drainage failure . 
 jaundice was reduced significatively in seven patients and a chemotherapy was started in 6/7 patientsconclusion : this pilot study shows the feasibility of this new technique to drain the right biliary duct in patients with hilar obstruction , with few major complications rates . 
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