ENDOSCOPIC DEPLOYMENT OF MULTIPLE (≥3) METAL STENTS FOR UNRESECTABLE MALIGNANT HILAR BILIARY STRICTURES: A COMBINATION OF SIDE-BY-SIDE AND STENT-IN-STENT METHODS (WITH VIDEO)

Aim:

The endoscopic deployment of multiple (≥3) self-expandable metal stents (SEMS) for high-grade unresectable malignant hilar biliary strictures (UMHBS) is technically challenging. We evaluated the efficacy of endoscopic deployment of multiple SEMS using a combination of side-by-side (SBS) and stent-in-stent (SIS) methods.

Methods:

Eleven consecutive patients with high-grade UMHBS (mean age: 76 years, male/female: 5/6, Bismuth-Corlette classification IIIa/IV: 7/4) underwent the endoscopic deployment of multiple SEMS using the combination technique. After the initial drainage with endoscopic biliary stenting and/or endoscopic nasobiliary drainage, SEMS were typically deployed as follows. After selective cannulation using a 0.025-inch guide wire, the SEMS were deployed in the right posterior sectoral duct and the left hepatic duct using the SBS method. Next, a 0.025-inch guide wire was introduced into the right anterior sectoral duct through the mesh of the SEMS on the right side. Then, the mesh of the stent was dilated with a 6-mm balloon, the guide wire was exchanged for a 0.035-inch stiff guide wire, and the delivery system was introduced. Finally, another SEMS was deployed in the right anterior sectoral duct using the SIS method.

Results:

The technical and clinical success rates were 11/11. More than three SEMS were successfully deployed, and obstructive jaundice was fully improved in all cases. Stent occlusion was recognized in 4 of 11 patients (mean: 134 days, range: 28 – 232). Reinterventions for both liver lobes were feasible by passing the guide wire inside the previously placed stents in 3 of 4 patients. The median stent patency was 150 days during a mean follow-up period of 184 days (range: 37 – 558). Three patients developed self-limiting cholangitis without definite stent occlusion as late (> 30 days) adverse events.

Conclusion:

Employing the combination of SBS and SIS methods may facilitate the endoscopic deployment of multiple SEMS to treat high-grade UMHBS.