Successful endoscopic three-branch self-expandable metallic stent placement using a novel device delivery system for malignant hilar biliary stricture

Endoscopic bilateral drainage of high-grade hilar malignant biliary obstruction (HMBO) is technically challenging, even for experienced endoscopists [1]. A novel device delivery system was recently developed, originally intended for placement of a plastic stent in the bile duct. It comprises a slim-tip guide catheter (diameter 1.13 mm) and pusher tube, which facilitate the insertion of devices up to 1.9 mm in diameter [2] [3] [4] [5]. We successfully placed an endoscopic three-branch self-expandable metallic stent (SEMS) using this novel device delivery system with partial stent-in-stent (SIS) for a patient with HMBO.

A 74-year-old man presented to our hospital with jaundice. Contrast-enhanced computed tomography showed that the hilar part of the tumor had spread to the umbilical portion of the portal vein with right hepatic artery involvement ([Fig. 1]). A cholangiogram showed hilar biliary stricture (Bismuth type IIIa) ([Fig. 2]). The pathological diagnosis with brush cytology was adenocarcinoma, so we planned multiple stenting using SEMSs with the SIS method.

Fig. 1 Contrast-enhanced computed tomography showed that the hilar part of the tumor had spread to the umbilical portion of the portal vein with right hepatic artery involvement (arrowheads).

Fig. 2 A cholangiogram showed high-grade malignant hilar biliary stricture with Bismuth type IIIa.

We placed the initial uncovered SEMS (10 × 80 mm, BileRush Selective; Piolax, Kanagawa, Japan) at the left bile duct and then inserted the second SEMS into the right posterior branch through the mesh. We sought the right anterior branch with a 0.025-inch hydrophilic guidewire (Radifocus; Terumo, Tokyo, Japan) and followed the tapered tip catheter (PR-220Q; Olympus Medical, Tokyo, Japan) after the guidewire, switching the hydrophilic guidewire to a 0.025-inch versatile guidewire (Endoselector; Boston Scientific, Tokyo, Japan). We inserted a third SEMS over the guidewire, but it could not be passed through the mesh ([Fig. 3]). We thus inserted the novel delivery system (EndoSheather; Piolax) over the guidewire, allowing smooth passage through the mesh ([Fig. 4]). After removing the inner catheter, we delivered the third SEMS (10 × 60 mm; BileRush Selective) through the outer sheath and successfully deployed it at the target site ([Fig. 5], [Video 1]).

Fig. 3 The third metallic stent could not be passed though the mesh (arrow).

Fig. 4 A novel device delivery system was able to be passed though the mesh (arrow).

Fig. 5 After removing the inner catheter, the third metallic stent was placed through the outer sheath (arrow, tip of the stent; arrowhead, proximal side of the stent).

Video 1 Successful endoscopic three-branch metallic stent placement using a novel device delivery system for malignant hilar biliary stricture.

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• References

• 1 Kawamoto H, Tsutsumi K, Fujii M. et al. Endoscopic 3-branched partial stent-in-stent deployment of metallic stents in high-grade malignant hilar biliary stricture (with videos). Gastrointest Endosc 2007; 66: 1030-1037
• 2 Matsumori T, Uza N, Shiokawa M. et al. Mapping biopsy for bile duct cancer using a novel device delivery system. Endoscopy 2021;
• 3 Matsumori T, Uza N, Okada H. et al. A novel technique for performing gallbladder tumor biopsy using a stent delivery system and biopsy forceps. Endoscopy 2020; 52: E415-E417
• 4 Okada H, Uza N, Matsumori T. et al. A novel technique for mapping biopsy of bile duct cancer. Endoscopy 2021; 53: 647-651
• 5 Nishikawa Y, Uza N, Yamauchi Y. et al. Successful endoscopic removal of fractured guidewire fragments from a peripheral bile duct using a biliary stent delivery system and biopsy forceps. Endoscopy 2018; 50: E279-E280