Bridging stenting via endosonographically created route (ESCR) is an alternative to
endoscopic transpapillary drainage for malignant hilar biliary obstruction (MHBO)
[1]
[2]
[3], with recent reports indicating superior stent patency compared to transpapillary
multi-stenting [4]. We report a case of MHBO with surgically altered anatomy in whom bridging stenting
across multiple metallic stents was successfully performed ([Video 1]).
Bridging stenting from the ESCR to the B6 across multiple metallic stents offers a
novel therapeutic option for complex cases of MHBO.Video 1
A 60-year-old man developed a Bismuth type IIIa stricture due to recurrent ampullary
carcinoma after pancreaticoduodenectomy ([Fig. 1]). Endoscopic ultrasound-guided hepaticogastrostomy was performed to the B2, and
uncovered self-expandable metallic stents (UCSEMSs) were placed into the anterior
and posterior bile ducts using the partial stent-in-stent method by balloon enteroscopy-assisted
endoscopic retrograde cholangiopancreatography. Furthermore, percutaneous transhepatic
biliary drainage (PTBD) was required to manage an isolated B6 ([Fig. 2]). Subsequently, bridging stenting from the ESCR to the isolated B6 was attempted
to internalize the PTBD ([Fig. 3]).
Fig. 1 Contrast-enhanced computed tomography (CT) shows a hypovascular tumor at the hepatic
hilum (arrowheads) and dilated bilateral intrahepatic bile ducts.
Fig. 2 Fluoroscopic image before bridging stenting shows the partially covered self-expandable
metallic stent (SEMS) in the endosonographically created route (ESCR) at the B2, two
uncovered SEMSs (UCSEMSs) in the anterior and posterior bile ducts, and the percutaneous
transhepatic biliary drainage (PTBD) tube in the isolated B6 bile duct.
Fig. 3 Schemas of bridging stenting from the ESCR to the isolated B6 across multiple metallic
stents. a The biliary stents and the PTBD tube before the procedure. b Guidewire insertion from the ESCR to the isolated B6. c An additional metallic stent placement from the ESCR to the B6. d Complete internal drainage of the entire liver.
A guidewire was initially advanced into the ESCR; however, seeking the isolated B6
through the mesh of previously placed UCSEMSs was challenging. Therefore, an additional
guidewire was advanced via the PTBD route as a landmark, enabling successful insertion
of the guidewire from the ESCR to the B6. Although an additional UCSEMS (8 mm × 60
mm; YABUSAME Neo; Kaneka Corporation, Osaka, Japan) was inserted, it failed to pass
through the mesh of the UCSEMSs. Therefore, a guide sheath (Endosheather; Piolax,
Kanagawa, Japan) was used to facilitate stent insertion, and the UCSEMS was successfully
placed from the B6 to the left hepatic duct ([Fig. 4]). As a result, complete internal drainage of the entire liver was achieved, allowing
removal of the PTBD tube and resumption of chemotherapy.
Fig. 4 Fluoroscopic images of bridging stenting from the ESCR to the B6 across multiple metallic
stents. a Seeking the isolated B6 from the ESCR through the mesh of the previously placed uncovered
self-expandable metallic stents (UCSEMSs) was challenging. b An additional guidewire (arrowhead) was advanced via the PTBD route as a landmark.
c The guidewire was successfully advanced from the ESCR to the B6. d An additional UCSEMS was inserted from the ESCR; however, it failed to pass through
the mesh of the UCSEMSs. e A guide sheath (arrowhead) was advanced into the B6 through the mesh of the UCSEMSs.
f The additional UCSEMS was successfully placed through the guide sheath from the B6
to the left hepatic duct. Contrast injection from the ESCR demonstrated a cross-shaped
bridging stenting.
To the best of our knowledge, this is the first report of bridging stenting from an
ESCR across multiple UCSEMSs, offering a novel therapeutic option for complex cases
of MHBO.
Endoscopy_UCTN_Code_TTT_1AS_2AH
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
