Endoscopic biliary drainage using “inside plastic stents” (iPSs) is favored for patients
with unresectable malignant hilar obstruction, because it offers prolonged stent patency
and easy reintervention [1 ]. However, one of the problems encountered in the endoscopic placement of multiple
iPSs is proximal dislocation of the preceding iPS during the subsequent iPS insertions.
Although several methods for preventing preceding iPS migration have been reported
[2 ]
[3 ], some devices are not immediately available. Herein, we report a case in which a
slip-knot was created using the threads of the preceding iPS ([Fig. 1 ]), to to perform the anchor-wire technique [4 ] for preventing its proximal dislocation during the endoscopic placement of the subsequent
iPS.
Fig. 1
a A slip-knot, formed as shown here, can be untied by simply pulling one end. b Slip-knot created using the threads of an inside plastic stent (iPS).
A 72-year-old man with malignant hilar obstruction due to gallbladder cancer was admitted
to our institution for acute cholangitis associated with recurrent biliary obstruction
([Fig. 2 ]). Endoscopic retrograde cholangiopancreatography was performed, and the initial
iPS (Through & Pass IS; Gadelius Medical, Tokyo, Japan) was removed. Although bilateral
drainage using iPSs was necessary, proximal dislocation of the preceding iPS was anticipated
because the biliary stenosis was severe. Therefore, a slip-knot was created in the
threads of the first iPS, before it was inserted. Because the preceding iPS was almost
dislocated proximally during the subsequent iPS insertion, anchor-wire technique was
performed using the thread’s loop formed with slip-knot [4 ]. Following this, the subsequent iPS was successfully inserted into the intrahepatic
bile duct through the hilar obstruction without dislocation of the preceding iPS and
placed in the appropriate position. After placement of the iPSs, the slip-knot threads
were straightened by pulling the end with a biopsy forceps passed through the working
channel of the duodenoscope ([Fig. 3 ], [Video 1 ]). This procedure requires only commonly used biopsy forceps additionally and is
easy to do.
Fig. 2 Computed tomography images. A 72-year-old man with malignant hilar obstruction due
to gallbladder cancer was admitted to our institution for acute cholangitis associated
with recurrent biliary obstruction.
Fig. 3 Fluoroscopic images of the procedure using the slip-knot method. a The first inside plastic stent (iPS), with a slip-knot in its threads, was inserted.
b This preceding iPS was almost dislocated proximally during the subsequent iPS insertion.
c Therefore the anchor-wire technique was performed using the slip-knot loop in the
threads of the preceding iPS. d The subsequent iPS was successfully inserted into the intrahepatic bile duct through
the hilar obstruction, without dislocation of the preceding iPS, and placed in the
appropriate position.
The slip-knot thread method for performing the anchor-wire technique to prevent proximal
dislocation of the preceding stent during placement of multiple biliary inside plastic
stents (iPSs).Video 1
The slip-knot thread method for performing the anchor-wire technique is useful for
preventing proximal dislocation of the preceding iPS during the endoscopic placement
of multiple iPSs.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
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