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Since endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumenapposingmetal stent was introduced first in an animal model in 2012 [1], and then in humans in 2015 [2], this technique has become more and more promising; it is now used in many expert centers around the world [3] to treat gastric outlet obstruction and to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. A 32-year-old woman with a history of right hepatectomy for a Klatskin IIIb cholangiocarcinoma (pT4N1pM1), with Rouxen-Y hepaticojejunostomy and incomplete chemotherapy, was referred to our center for sepsis with cholestasis and cytolysis. CTscan revealed a dilated intrahepatic bile duct and dilated afferent jejunal limb in contact with carcinoid lymph node metastasis (▶Fig. 1, ▶Video 1). After multidisciplinary discussion, we decided to perform an endoscopic ultrasound-directed transgastric ERCP (EDGE) in one single session. First, under sonographic guidance in the stomach, a 10-cm dilated jejunal limb was seen, and a 15-mm Hot Axios stent system (Boston Scientific, New York, USA) was deployed to form a gastroenterostomy. Then we dilated the anastomosis with a 12-mm balloon to facilitate the passage into the jejunal limb of a conventional gastroscope. Next, the biliary anastomotic orifice was located and cannulated with a sphincterotome. Some small dilation of the orifice was achieved through repeated passing of the sphincterotome (▶Fig. 2, ▶Fig. 3). In this way we achieved good emptying of the bile duct without the need for biliary stenting at the end of the procedure (▶Fig. 4). No related adverse event occurred after the procedure. The patient was discharged home 24h later E-Videos

Single-step endoscopic ultrasound-guided gastroenterostomy and ERCP in patient with Roux-en-Y hepaticojejunostomy after right lobe hepatectomy