This is the video regarding clip and line technique for biliary drainage in case of recurrent biliary obstructions. In US HES long length stents are used to prevent stent inward migration into the peritoneal cavity and to have a long term stent patency. This long length will create technical difficulties if there is a need for reintervention in biliary obstructions. For interventions, three approaches are used, one through the distal end of the stent, one through the stent mesh and one through the HGS fistula created after removing the stent. Once the guide wire is inside, the further reinterventions are performed. A 47-year-old female presented with hyaluradenocarcinoma with metastasis and duodenal narrowing and SITs. She underwent US-guided hepatic gastrostomy one month back and now presented with obstructive jaundice and fever which is suggestive of a recurrent biliary obstruction. Three approaches of endoscopic reintervention have been tried in this lady of which two have failed and the third one that is removal of the stent for the fistula has been not attempted because it is only one month since the insertion of the stent and there is SITs. So endoscopic clip in line technique has been used using the same principles as in ESD and the clip is placed at the distal end of the HGS stent and pulled through oral side. Since the intragastric length is long, HGS stent could be pulled into the esophagus which prevented the kinking of the stent. By keeping the traction by holding the line at the mouth is continued till the completion of the procedure. Once the procedure is done, the line is left pushing the stent restoring to its original position. The stent can be either cut by a loop cutter or left in the stomach. There is a duodenal narrowing preventing the scope to be passed to reach the papilla and you can see the HGS stent which is very long almost touching the opposite wall eroding it. First approach by passing the wire across the end of the stent has been tried in the retroflexion first but the angle of the stent does not allow the wire or the accessory to pass through the end of the stent. Through the end of the stent in the forward position has been tried but still the angle is not so good to allow the accessory or the guide wire to be placed across the stent into the biliary system. So, the second approach that is passing the wire through the stent mesh has been tried by using the toe. The wire could pass through but for the deep wire passage, the accessory is not able to pass through the stent mesh. So, repeated tries with different accessories like dilator, cannula have been tried but they all resulted in failure. So, the endoclip and dental floss tied to its end has been used to place over the distal end of the stent to serve as an anchor for traction and the HGA stent is pulled up by using that wall eye and the stent can be put in a nice axis for the accessories to pass easily. If the stent length is too long, the stent can be easily pulled back right into the esophagus which will provide enough support to prevent any kinking of the stent. So, once the stent has been stabilized by giving the traction, all the accessories can be passed through the stent. Once the stent is held in place by traction, the guide wire is passed by means of a toe and the guide wire is passed deep across the hyalum into the CVD and then other accessories like balloon can be used to clear the contents of the stent. These are the fluoroscopic images of the procedure which show the stent being pulled up into the esophagus and having a straight axis to the biliary system through which accessories can be passed across the guide wire and balloon can be used to trawl the stent and clear the CHD and stent of the contents and we can put a contrast to delineate the biliary tree and pass a stent across the strictures into the digital CVD or into the duodenum and across the wire, the stents can be placed to aid in the biliary drainage. Post stenting, the lady got better with reduction of jaundice and fever. She continued chemotherapy and lived for another 4.5 months. Clinical implications of the case, clip and line method is simple, affordable, effective and reliable. It provides a good traction and good axis for easy passage of accessories required for intervention especially in case of high-loss strictures. Less time is required and it doesn't damage the stems. And good choice of method for cases requiring contrast injection since there is less leakage of contrast. Hence, it has the potential to become the first choice of endoscopic approach for re-intervention in cases of recurrent biliary obstruction. In conclusion, clip and line technique used for traction in third space can be used in cases of HES with recurrent obstruction and it can be used as the initial method. Further research is warranted to compare it with other methods.

biliary drainage

clip and line technique

stent migration prevention

high-loss strictures

recurrent obstructions