A 37-YEAR-OLD MAN with stage IV gastric cancer was taken to our hospital for jaundice. He had a previous history of gastrojejunostomy for pyloric stenosis and had received chemotherapy for a year. His laboratory examination showed obstructive jaundice and contrastenhanced computed tomography (CECT) revealed ascites and severe dilation of the intrahepatic bile duct with the stricture around the common hepatic duct by peritoneal dissemination of the gastric cancer. As pyloric stricture caused by gastric cancer disturbed endoscopic retrograding cholangiopancreatography (ERCP), endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) was alternatively performed as a first biliary drainage (Fig. 1). One month later, two plastic stents were inserted into B3 as an additional drainage because the jaundice was not improved enough. Sixty-eight days after the initial biliary drainage, recurrent biliary obstruction occurred. CECT revealed that biliary stricture was spread beyond the bifurcation of the common hepatic duct. Endoscopic naso-biliary drainage tubes (ENBD) were placed into right anterior and posterior branches through the EUS-HGS fistula and cholangiography showed that right anterior and posterior branches were separated (Fig. 2). Therefore, two covered self-expanding metallic stents (cSEMS; Niti-S Biliary S-type Stent, 120 mm 9 8 mm; Taewoong Medical, Kimpo-gun, Korea) for both branches were successfully placed through the EUS-HGS fistula without any adverse events (Video S1). The patient died 2 months after the procedure without any adverse events or stent dysfunctions. EUS-guided biliary drainage including EUS-HGS in patients with obstructive jaundice due to advanced gastric cancer has been reported in cases of ERCP failure. Herein, we described the first case in which multiple metallic stents were placed through the EUS-HGS fistula. This case suggests that multiple

中文翻译：

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一种内镜超声引导下肝胃造瘘瘘的多支架技术治疗恶性肺门梗阻

一名患有 IV 期胃癌的 37 岁男性因黄疸被送往我院。他既往因幽门狭窄接受过胃空肠吻合术，并接受了一年的化疗。他的实验室检查显示梗阻性黄疸和对比增强计算机断层扫描 (CECT) 显示腹水和肝内胆管严重扩张，胃癌腹膜播散导致肝总管周围狭窄。由于胃癌引起的幽门狭窄干扰了内镜逆行胰胆管造影 (ERCP)，因此内镜超声引导下肝胃造口术 (EUS-HGS) 被替代地作为第一次胆道引流（图 1）。一个月后，因为黄疸没有得到足够的改善，在B3中插入了两个塑料支架作为额外的引流。首次胆道引流后 68 天，再次发生胆道梗阻。CECT 显示胆道狭窄已扩散到肝总管分叉以外。经 EUS-HGS 瘘管将内窥镜鼻胆管引流管（ENBD）置入右前、后支，胆管造影显示右前、后支分离（图 2）。因此，两个分支的两个覆膜自膨式金属支架（cSEMS；Niti-S Biliary S 型支架，120 mm 9 8 mm；Taewoong Medical，Kimpo-gun，Korea）通过 EUS-HGS 瘘管成功放置，没有任何不良事件（视频 S1）。患者在手术后 2 个月死亡，没有任何不良事件或支架功能障碍。据报道，在 ERCP 失败的情况下，EUS 引导的胆道引流包括 EUS-HGS 用于晚期胃癌引起的梗阻性黄疸患者。在此，我们描述了通过 EUS-HGS 瘘放置多个金属支架的第一个案例。该案例表明，多个