Endoscopy 2014; 46(S 01): E472-E473
DOI: 10.1055/s-0034-1377541
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Multiple metal stenting using a double-balloon endoscope for malignant biliary obstruction in a patient with hepaticojejunostomy

Hirofumi Kogure
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Atsuo Yamada
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Hiroyuki Isayama
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Tomotaka Saito
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Tsuyoshi Hamada
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Takashi Sasaki
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Natsuyo Yamamoto
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Yousuke Nakai
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Kenji Hirano
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Minoru Tada
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
,
Kazuhiko Koike
Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
› Author Affiliations
Further Information

Corresponding author

Hirofumi Kogure, MD
Department of Gastroenterology
Graduate School of Medicine
University of Tokyo
7-3-1 Hongo, Bunkyo-ku
Tokyo 113-8655
Japan   
Fax: +81-3-38140021   

Publication History

Publication Date:
14 October 2014 (online)

 

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]).

Zoom Image
Fig. 1 The first uncovered metal stent was deployed into the anterior branch of the right hepatic duct.
Zoom Image
Fig. 2 The catheter was advanced into the posterior branch of the right hepatic duct through the first stent mesh.
Zoom Image
Fig. 3 The second uncovered metal stent (UMS) was deployed through the mesh of the initial UMS.
Zoom Image
Fig. 4 The catheter was passed into the lateral branch of the left hepatic duct through the overlapping stent mesh.
Zoom Image
Fig. 5 The third uncovered metal stent (UMS) was deployed through the mesh of the initial and second UMSs.

Endoscopy_UCTN_Code_TTT_1AR_2AZ


#

Competing interests: None

  • References

  • 1 Shimatani M, Matsushita M, Takaoka M et al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy 2009; 41: 849-854
  • 2 Tsujino T, Yamada A, Isayama H et al. Experiences of biliary interventions using short double-balloon enteroscopy in patients with Roux-en-Y anastomosis or hepaticojejunostomy. Dig Endosc 2010; 22: 211-216
  • 3 Chennat J, Waxman I. Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction. Gastrointest Endosc 2010; 72: 632-636

Corresponding author

Hirofumi Kogure, MD
Department of Gastroenterology
Graduate School of Medicine
University of Tokyo
7-3-1 Hongo, Bunkyo-ku
Tokyo 113-8655
Japan   
Fax: +81-3-38140021   

  • References

  • 1 Shimatani M, Matsushita M, Takaoka M et al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy 2009; 41: 849-854
  • 2 Tsujino T, Yamada A, Isayama H et al. Experiences of biliary interventions using short double-balloon enteroscopy in patients with Roux-en-Y anastomosis or hepaticojejunostomy. Dig Endosc 2010; 22: 211-216
  • 3 Chennat J, Waxman I. Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction. Gastrointest Endosc 2010; 72: 632-636

Zoom Image
Fig. 1 The first uncovered metal stent was deployed into the anterior branch of the right hepatic duct.
Zoom Image
Fig. 2 The catheter was advanced into the posterior branch of the right hepatic duct through the first stent mesh.
Zoom Image
Fig. 3 The second uncovered metal stent (UMS) was deployed through the mesh of the initial UMS.
Zoom Image
Fig. 4 The catheter was passed into the lateral branch of the left hepatic duct through the overlapping stent mesh.
Zoom Image
Fig. 5 The third uncovered metal stent (UMS) was deployed through the mesh of the initial and second UMSs.