Handmade snare technique for grasping and repositioning biliary stents via the endoscopic ultrasound-guided hepaticojejunostomy route

Permissions and Reprints (opens in new window) Endoscopic ultrasound-guided hepaticogastrostomy/hepaticojejunostomy (EUS-HGS/HJS) is an established alternative to endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy [ 1 ] [ 2 ]. When combined with antegrade transpapillary stenting (AGS), dual-route biliary drainage can be secured [ 3 ] [ 4 ]; however, troubleshooting often requires balloon-assisted endoscopy. A 65-year-old man with surgically altered anatomy and multiple comorbidities presented with septic shock due to choledocholithiasis-related cholangitis. Emergency EUS-HJS was performed to achieve rapid decompression because definitive stone extraction was not feasible at that time. A plastic stent was placed antegradely across the papilla (AGS), and an endoscopic nasobiliary drainage (ENBD) tube was added ([ Fig. 1 ]). Fig. 1 A fluoroscopic image showing an antegrade plastic stent placed across the papilla with its distal end in the duodenum (yellow arrowheads) and an endoscopic nasobiliary drainage tube traversing the endoscopic ultrasound-guided hepaticogastrostomy route (red arrowheads). Two weeks later, ENBD cholangiography confirmed stone clearance, and internalization was planned because fistula maturation was uncertain and reintervention without balloon-assisted endoscopy was desirable at the receiving hospital; stent exchange via the HJS route was planned if cholangitis recurred. A standard guidewire was advanced via the ENBD and left in place as a rescue wire in case the stent migrated completely into the bowel; the ENBD tube was removed. A handmade snare was advanced through the HJS tract alongside the rescue wire. As previously reported [ 5 ], the snare was constructed by inserting both ends of a 0.025-inch flexible hydrophilic guidewire commonly used for ERCP in Japan (Radifocus; Terumo, Japan) into the two lumens of a double-lumen catheter (Uneven Double Lumen Cannula; Piolax Medical Devices, Japan; distal outer diameter: 3.6 Fr). Due to the limited wire length, the proximal end of the catheter was cut to externalize both wire ends, creating a soft loop with the wire exiting from the two distal holes ([ Fig. 2 ]). The loop was used to grasp the stent flap and reposition the stent to the HJS anastomosis; patency was confirmed ([ Fig. 3 ], [ Video 1 ]). Fig. 2 Schema of the handmade snare constructed from an uneven double-lumen catheter. a The two ends of a guidewire are inserted through the two lumens of the catheter to form a distal snare loop. The loop is kept closed so that it does not interfere with insertion. b Pushing the guidewires from the proximal side advances and opens the snare loop, forming a grasping device. Fig. 3 Repositioning a plastic stent via the endoscopic ultrasound-guided hepaticogastrostomy or hepaticojejunostomy (HGS/HJS) route using the handmade snare. In all panels, the grasping portion of the plastic stent is indicated by red circles. a Schema showing the distal end of the plastic stent across the papilla being grasped with the handmade snare advanced through the endoscopic ultrasound-guided HGS/HJS route. b Schema showing the plastic stent being pulled back and repositioned to the HGS/HJS anastomosis. c A fluoroscopic image corresponding to ( a ), showing grasping of the plastic stent with the handmade snare. d A fluoroscopic image corresponding to ( b ), showing the plastic stent relocated to the HGS/HJS anastomosis. Download Video Handmade snare–assisted repositioning of an antegrade transpapillary plastic stent via the endoscopic ultrasound-guided hepaticojejunostomy (EUS-HJS) route, achieving internalization and preserving biliary access without balloon-assisted enteroscopy.Video 1 This HJS-based technique provides a simple approach for transpapillary stent management without the need for balloon-assisted endoscopy. Endoscopy_UCTN_Code_CCL_1AF_2AF_3AB Endoscopy_UCTN_Code_TTT_1AR_2AZ Publication History Article published online: 17 February 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany