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Enteroscopy is useful for approaching anastomotic stenoses; however, in surgically altered anatomy, success rates of 70%–80% have been reported [1]. Alternatively, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) may be acceptable [2]. Usually, one EUS-HGS is performed; however, double EUS-HGS is required for two-hole anastomotic stenosis to resolve symptoms. We report the first case of successful double EUSHGS for two-hole benign anastomotic stenosis. An 89-year-old woman had a history of right hepatic trisegmentectomy, and Roux-en-Y reconstruction for bile duct cancer 10 years prior to presentation. Percutaneous transhepatic biliary drainage (PTBD) was previously performed for B3 to treat cholangitis due to anastomotic stenosis, but cholangitis was poorly controlled because B2 and B3 were separately anastomosed. PTBD revealed that both had stenoses (▶Fig. 1). Endoscopic retrograde cholangiography was performed using double-balloon enteroscopy, but adhesion prevented the enteroscope from reaching the anastomosis. EUS-HGS was performed instead. Double EUS-HGS was temporarily applied to B2 Video 1 Both B2 and B3 anastomoses had stenoses. First, double endoscopic ultrasound-guided hepaticogastrostomy was performed. Second, we deployed a fully covered metal stent to the anastomosis. All stents were removed 2 months later. ▶ Fig. 1 Plain computed tomography (CT) scan image and intrahepatic bile duct enhancement via percutaneous transhepatic biliary drainage. Both B2 and B3 biliary anastomoses had stenosis. a Plain CT scan image. The arrow indicates the anastomosis. b Intrahepatic bile duct enhancement via PTBD. The arrow indicates the anastomosis. E-Videos

Novel double endoscopic ultrasound-guided hepaticogastrostomy for two-hole benign anastomotic stenosis with difficult gastrointestinal approach