The combined stent-by-stent (SBS) and stent-in-stent (SIS) technique (SBSIS) can make
tri-sectoral metal stenting for malignant hilar biliary obstruction (MHBO) straightforward
[1]
[2]. However, it is challenging to perform SBSIS in patients with surgically altered
anatomy (SAA). Here, we report a successful case of SBSIS deployment in a patient
with SAA, using a forward-oblique viewing echoendoscope.
A 91-year-old-man who had distal gastrectomy with Billroth-II reconstruction developed
obstructive jaundice due to Bismuth IIIa MHBO that extended to the duodenal papilla.
We inserted a forward-oblique viewing echoendoscope (EG-580UT; Fujifilm, Tokyo, Japan)
and succeeded in reaching the duodenal papilla. After wire-guided biliary cannulation,
two 0.025-inch guidewires were placed in the right posterior superior segmental and
left hepatic ducts, followed by simultaneous insertion of two 5.4F-diameter delivery
systems (ZeoStent V; Zeon Medical, Tokyo, Japan). The posterior stent was subsequently
deployed across the stricture, and a 3-Fr microcatheter (Hanako Medical, Saitama,
Japan) [3] was introduced over the posterior guidewire, and then the guidewire was advanced
into the anterior hepatic duct through the stent mesh. An additional metal stent with
a 5.4 F delivery system was inserted without the need for any dilation and deployed
in the anterior duct in a SIS manner. Finally, the left stent was released and deployed
in a SBS manner ([Fig. 1], [Fig. 2], and [Video 1]). The procedure was completed without any hindrance or adverse events.
Fig. 1 a After insertion of the forward-oblique viewing echoendoscope up to the duodenal papilla,
two 0.025-inch guidewires were placed in the posterior and left hepatic ducts, followed
by simultaneous insertion of two 5.4-Fr-diameter delivery systems. b After the posterior stent was deployed across the stricture, the guidewire was advanced
into the anterior duct through the stent mesh. c An additional 5.4F metal stent was inserted and deployed in the anterior duct in
a stent-in-stent manner. d Finally, the left stent was released and deployed in a stent-by-stent manner.
Fig. 2 Three-dimensional reconstruction using computed tomography after the combined stent-by-stent
and stent-in-stent deployment.
Video 1 Combined simultaneous stent-by-stent and stent-in-stent metal stent deployment using
the forward-oblique viewing echoendoscope for a case with malignant hilar biliary
obstruction and surgically altered anatomy.
The echoendoscope, which provides a forward endoscopic view and a wider bending capacity
to up to 150 degrees, may enable insertion deep into the jejunum of patients with
SAA [4]
[5]. Moreover, the scope has a working channel diameter of 3.8 mm to allow simultaneous
insertion of two delivery systems, and the forceps elevator enables easier device
advancement ([Fig. 3]). Therefore, the scope can serve as a useful alternative when performing tri-sectoral
metal stenting for patients with MHBO and SAA.
Fig. 3 a The echoendoscope, which provides a forward endoscopic view and a flexible scope tip,
may enable insertion deep into the jejunum of patients with surgically altered anatomy.
b The scope has a working channel diameter of 3.8 mm to allow simultaneous insertion
of two delivery systems, and the forceps elevator enables device advancement easier.
