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Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is one of the biliary drainage options for patients in whom endoscopic retrograde cholangiopancreatography (ERCP) fails [1, 2]. Technical tips for EUS-HGS are divided into several steps [3]. Among these steps, guidewire manipulation is one of most challenging parts of EUS-HGS [4]. In achieving successful guidewire insertion, selection of the guidewire is an important issue. A novel, 0.025-inch guidewire has recently become available in Japan (MICHISUJI; KANEKA Medical, Osaka, Japan) (▶Fig. 1). High flexibility, which is one of the characteristics of this guidewire, plays an especially important role in the safe guidewire technique, which we call “knuckle guidewire insertion” [5]. Herein, we describe technical tips for “reverse” knuckle guidewire insertion during EUS-HGS. A 78-year-old man underwent percutaneous transhepatic biliary drainage beE-Videos

Reverse knuckle guidewire insertion technique for endoscopic ultrasound-guided hepaticogastrostomy using a novel 0.025-inch guidewire