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Endoscopic ultrasound (EUS)-guided drainage procedures, such as pancreatic pseudocyst drainage, biliary drainage, and gallbladder drainage, arebeing increasingly performed in specialist centers [1–4]. A 30-year-old man with unresectable periampullary cancer, who had undergone biliary plastic stenting 1 year previously, presented with recurrent jaundice and gastric outlet obstruction for 2 weeks. Blood test results showed his bilirubin was 15mg/dL with an alkaline phosphatase of 800u/L. An ultrasound of his abdomen showed dilated intrahepatic biliary radicals and a dilated bile duct with a periampullary mass. Side-viewing endoscopy was unsuccessful despite dilation of the gastric outlet. EUSguided choledochoduodenostomy failed because the bile duct, which was thickened due to the plastic stent, could not be punctured with a 19G fine needle aspiration (FNA) needle (●" Fig.1). EUS-guided cholecystogastrostomy was therefore performed using a silicone-covered nitinol stent (14mm in diameter, 20-mm long) with bilateral 24-mm diameter anchor flanges (Nagi; Taewoong Medical Co. Ltd., Seoul, Korea) (●" Fig.2). This stent provides stability and minimizes migration. The diameter of the delivery system is 10Fr. The gallbladder was visualized using a linear echoendoscope (GF-UCT 180; Olympus) at the level of the antrum and was punctured with a 19G needle (Cook Endoscopy, Winston-Salem, North Carolina, USA) (●" Fig.3). After removal of the stylet, bile was aspirated, and contrast was injected into the gallbladder, revealing a patent cystic duct. A 0.035-inch guidewire (Jagwire; Boston Scientific, Natick, Massachusetts, USA) was inserted into the gallbladder under fluoroscopic guidance. The needle was removed and the puncture site was dilated using 6-Fr and 7-Fr dilators (Soehendra biliary catheters; Cook Endoscopy) and then with a 4-mm balloon (Hurricane; Boston Scientific, Tokyo, Japan) (●" Fig.4a). Finally, a Nagi stent (Taewoong Medical Co. Ltd.) was deployed across the cholecystogastrostomy tract (●" Fig.4b). The procedure resulted in biliary decompression with resolution of the patient’s jaundice. The biliary plastic stent was removed using an upper gastrointestinal endoscope. A 9-cmmetal stent was placed across the duodenal stricture (●" Fig.5; ●" Video 1). The patient remains asymptomatic after 4 weeks of follow up.

endoscopy

First report of endoscopic ultrasound-guided cholecystogastrostomy with a Nagi covered metal stent for palliation of jaundice in extrahepatic biliary obstruction