Novel side-by-side metal stent placement for recurrent hepatic hilar obstruction after placement of multiple metal stents
Endoscopic re-intervention following placement of multiple self-expandable metal stents (SEMSs) is challenging   . A suitable re-intervention for malignant hilar biliary obstruction (MHBO) is not available. Plastic stents are used for re-intervention following placement of multiple SEMSs, but advancing the plastic stents through the mesh of the SEMS is difficult. This report describes successful side-by-side (SBS) metal stent deployment for recurrent MHBO after placement of SEMSs.
A 69-year-old man underwent endoscopic multistent drainage (8 mm × 8 cm and 8 mm × 6 cm; BileRush Selective; Piolax, Kanagawa, Japan) using a partial stent-in-stent (SIS) technique for MHBO due to a recurrent lesion after left lobectomy for left intrahepatic cholangiocarcinoma ([Fig. 1]). His obstructive jaundice recurred 7 months later. A contrast-enhanced computed tomography (CT) scan ([Fig. 2]) and endoscopic retrograde cholangiography (ERC) ([Fig. 3 a]) revealed recurrent hilar obstruction due to tumor ingrowth and overgrowth.
Endoscopic re-intervention was performed. Two 0.025-inch guidewires (VisiGlide 2; Olympus, Tokyo, Japan) were inserted into the dilated anterior and posterior branches, and two laser-cut SEMSs (8 mm × 8 cm; BileRush Selective; Piolax) with 5.7-Fr delivery systems were simultaneously inserted over the guidewires without balloon dilation of the stent mesh ([Fig. 3 b]; [Video 1]). The stents were then deployed in the optimal positions using the SBS technique ([Fig. 3 c, d]). [Fig. 4] shows the post-insertion CT images. His total bilirubin level improved from 4.4 mg/dL to 1.7 mg/dL within 14 days. Three months later, he succumbed to underlying disease but without experiencing occlusion of the SEMSs.
Video 1 Simultaneous side-by-side self-expandable metal stent (SEMS) placement as re-intervention for occlusion of SEMSs previously placed using the stent-in-stent technique.
Re-intervention using SBS placement of metal stents has two advantages over plastic stents. First, the thin SEMS delivery systems are simpler to advance and track, and easily penetrate the mesh for stent deployment. Second, SEMSs have longer patency than plastic stents .
This is the first report of the placement of simultaneous SBS SEMSs for re-intervention in recurrent MHBO following placement of multiple SEMSs. This innovative, efficacious method may be considered after the placement of multiple SEMSs.
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
04 March 2020 (online)
© Georg Thieme Verlag KG
Stuttgart · New York
- 1 Inoue T, Naitoh I, Okamura F. et al. Reintervention for stent occlusion after bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction. Dig Endosc 2016; 28: 731-737
- 2 Okuno M, Mukai T, Iwashita T. et al. Evaluation of endoscopic reintervention for self-expandable metallic stent obstruction after stent-in-stent placement for malignant hilar biliary obstruction. J Hepatobiliary Pancreat Sci 2019; 26: 211-218
- 3 Kawakami H, Itoi T, Kuwatani M. et al. Technical tips and troubleshooting of endoscopic biliary drainage for unresectable malignant hilar biliary obstruction. J Hepatobiliary Pancreat Sci 2015; 22: E12-E21