Endoscopic management of malignant biliary obstruction following hepaticojejunostomy
can be challenging. With the advent of the short double-balloon endoscope (DBE), therapeutic
biliary interventions are possible in surgically altered anatomy [1]
[2]. Additionally, a novel uncovered metal stent (UMS) has been developed with a 200-cm-long,
6-Fr delivery system (Zilver 635; Cook Medical, Winston-Salem, North Carolina, United
States) to enable metal stent placement using a short DBE [3]. We present a successful case of multiple metal stenting using a short DBE and UMS
for malignant biliary obstruction after hepaticojejunostomy.
A 75-year-old man with extrahepatic bile duct cancer underwent pancreaticoduodenectomy
with Roux-en-Y reconstruction. He developed cholangitis 11 months postoperatively
as a result of liver metastasis in the medial left lobe segment. Endoscopic retrograde
cholangiopancreatography (ERCP) was performed to place two plastic stents using a
short DBE (EI-530B; Fujifilm Corp., Tokyo, Japan). However, rapid tumor growth resulted
in recurrent episodes of cholangitis. Therefore, the decision was made to insert multiple
metal stents via another ERCP using the short DBE.
The plastic stents were removed, and the hepaticojejunostomy anastomosis was cannulated.
A 0.025-inch stiff guidewire (Revowave; Piolax Medical Devices, Yokohama, Japan) was
placed into the anterior right hepatic duct branch, and the UMS was inserted using
the 6-Fr delivery system ([Fig. 1]). A seeking guidewire (Radifocus; Terumo, Tokyo, Japan) sought the posterior right
hepatic duct branch through the stent mesh, and the catheter was advanced through
the stent mesh ([Fig. 2]). The guidewire was exchanged for a stiff guidewire. The second UMS was deployed
([Fig. 3]). Subsequently, a seeking guidewire sought the lateral left hepatic duct branch
through the overlapping stent mesh. The catheter could then be passed through the
overlapping stent mesh ([Fig. 4]). The guidewire was exchanged. Finally, the third UMS was smoothly deployed into
the lateral left hepatic duct using a stent-in-stent method ([Fig. 5]).
Fig. 1 The first uncovered metal stent was deployed into the anterior branch of the right
hepatic duct.
Fig. 2 The catheter was advanced into the posterior branch of the right hepatic duct through
the first stent mesh.
Fig. 3 The second uncovered metal stent (UMS) was deployed through the mesh of the initial
UMS.
Fig. 4 The catheter was passed into the lateral branch of the left hepatic duct through
the overlapping stent mesh.
Fig. 5 The third uncovered metal stent (UMS) was deployed through the mesh of the initial
and second UMSs.
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