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Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a well-established treatment option for benign biliary diseases after failure of conventional procedures [1]. A two-step approach of cholangioscopy-assisted management for a difficult biliary stone through an EUSguided bilioenteric fistula has previously been reported [2]. Cholangioscopyguided electrohydraulic lithotripsy (EHL) is currently considered one of the effective methods for stone removal, with clearance rates of 69% and 97% in single and multiple sessions, respectively [3]. Nevertheless, the high cost of digital cholangioscopy has limited its use in many centers [4]. Herein, we present a modified device that enabled EHL to be performed using a conventional ultraslim endoscope for a difficult biliary stone after EUS-BD. The patient was an 80-year-old woman who presented with fever and jaundice. Her past history was significant for a gastroduodenostomy after gastric outlet obstruction with severe duodenal stenosis complicating acute pancreatitis. An EUS-guided choledochoduodenostomy (CDS) was performed later (3 years prior to this presentation) after an attack of E-Videos

A unique device enabling electrohydraulic lithotripsy with an ultraslim scope for difficult stones after endoscopic ultrasound-guided biliary drainage