Double guidewire technique stabilization procedure for endoscopic ultrasound-guided hepaticogastrostomy involving modifying the guidewire angle at the insertion site

Background and aims: Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is often performed using a single guidewire (SGW), but the efficacy of the double guidewire (DGW) technique during endoscopic ultrasonography-guided biliary drainage has been reported. We evaluated the efficacy of the DGW technique for EUS-HGS, focusing on the guidewire angle at the insertion site. Methods: This retrospective cohort study included consecutive patients who underwent EUS-HGS between April 2012 and March 2021. We measured the guidewire angle at the insertion site using still fluoroscopic imaging. We compared the clinical outcomes of EUS-HGS with the DGW and SGW techniques. The factors associated with successful cannula insertion, need for additional fistula dilation and adverse event rate were assessed by a logistic regression multivariable analysis. Results: The DGW group showed higher technical (p = 0.020) and clinical success rates (p = 0.016) than the SGW group, which showed more adverse events (p = 0.017) than the DGW group. Successful cannula insertion was associated with a guidewire angle > 137° and an uneven double-lumen cannula. The DGW technique made the guidewire angle obtuse at the insertion site (p < 0.0001). A guidewire angle ≤ 137° (OR, 35.6; 95% CI, 1.70–744; p = 0.0045) and intrahepatic bile duct diameter of the puncture site ≤ 3.0 mm (OR, 14.4; 95% CI, 1.37–152; p = 0.0056) were risk factors for needing additional fistula dilation in a multivariate analysis, and additional dilation was a significant predictive factor for adverse events (OR, 8.3; 95% CI, 0.9–77; p = 0.026). Conclusions: The DGW technique can modify the guidewire angle at the insertion site and facilitate stent deployment with few adverse events.