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 Table of Contents  
IMAGES AND VIDEOS
Year : 2021  |  Volume : 10  |  Issue : 5  |  Page : 387-389

EUS-guided antegrade metallic stent placement using the stent-in-stent method with a 6-Fr novel slim delivery system in a patient with malignant hilar biliary obstruction


1 Department of Gastroenterology and Hepatology, Yamaguchi University Graduate, School of Medicine, Ube, Japan
2 Department of Gastroenterology, Tokuyama Central Hospital, Shunan, Japan

Date of Submission10-Oct-2020
Date of Acceptance04-Jan-2021
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. Shigeyuki Suenaga
Department of Gastroenterology and Hepatology, Yamaguchi University Graduate, School of Medicine, Ube
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EUS-D-20-00225

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How to cite this article:
Suenaga S, Kaino S, Tsuyama T, Fujimoto Y, Amano S, Uekitani T, Sakaida I. EUS-guided antegrade metallic stent placement using the stent-in-stent method with a 6-Fr novel slim delivery system in a patient with malignant hilar biliary obstruction. Endosc Ultrasound 2021;10:387-9

How to cite this URL:
Suenaga S, Kaino S, Tsuyama T, Fujimoto Y, Amano S, Uekitani T, Sakaida I. EUS-guided antegrade metallic stent placement using the stent-in-stent method with a 6-Fr novel slim delivery system in a patient with malignant hilar biliary obstruction. Endosc Ultrasound [serial online] 2021 [cited 2021 Nov 27];10:387-9. Available from: http://www.eusjournal.com/text.asp?2021/10/5/387/314172

A 72-year-old male was admitted with anorexia and jaundice caused by advanced gastric cancer with bismuth type II hilar biliary stricture due to invasion of gastric cancer [Figure 1]. A gastro-duodenal stent was deployed to treat malignant gastric outlet obstruction [Figure 2]. After 2 days, the gastro-duodenal stent expansion was insufficient to insert the duodenoscope. Therefore, EUS-guided biliary drainage (EUS-BD) was conducted. In addition, as there was food residue in the stomach, transpapillary drainage was performed considering the risk of stent obstruction and retrograde infection.
Figure 1: (a) Computed tomography showing hilar biliary obstruction (arrow). (b) Computed tomography showing gastric outlet obstruction. (c) Computed tomography showing common bile duct (red arrowhead) was invaded (arrow) by gastric cancer (*)

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Figure 2: (a) Endoscope and gastrography showing gastric outlet obstruction due to advanced gastric cancer. (b) A gastro-duodenal stent is placed to treat malignant gastric outlet obstruction

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The dilated B3 segment was punctured using a 19-gauge needle. A 0.025-inch guidewire was inserted into the duodenum through the papilla. A cholangiogram showed a 30-mm stricture in the hilar biliary duct and displacement of the left and right hepatic ducts [Figure 3]. A double-lumen cannula was inserted, followed by a 0.035-inch guidewire to stabilize the axis. A 0.025-inch guidewire was inserted into the right anterior B5 segment. The stricture was dilated using a 4-mm balloon. An uncovered self-expandable metal stent (SEMS), with a slim delivery system (Niti-S large cell SR slim delivery; 6-Fr diameter; Taewoong Medical, Seoul, Korea) was inserted to bridge the hepatic ducts [Figure 4]. Next, a 0.025-inch guidewire was introduced into the duodenum, beyond the papilla, through the stent mesh. The stricture and stent mesh were dilated using a 4-mm balloon. Another uncovered SEMS (Niti-S large cell SR slim delivery) was deployed from the distal common bile duct to the left hepatic duct using a stent-in-stent method. A plastic stent was placed from the intrahepatic duct to the stomach to maintain the access route [Figure 5]. After 6 days, the serum bilirubin level improved and he was discharged with no complications. At the 3-month follow-up, the patient was receiving chemotherapy and doing well.
Figure 3: (a) The dilated B3 segment is punctured using a 19-gauge needle under EUS-guidance. (b) Cholangiography showing hilar biliary duct stricture and displacement of the left and right hepatic ducts (arrow)

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Figure 4: (a) A guidewire inserted into the right anterior B5 segment. (b) The stricture is dilated with a balloon. (c) A self-expandable metal stent is placed bridging the right and left hepatic ducts

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Figure 5: (a) The stricture and stent mesh are dilated with a balloon. (b) A self-expandable metal stent is deployed using the stent-in-stent method. (c) X-ray image after EUS-guided biliary drainage

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EUS-BD has become a rescue treatment option for endoscopic retrograde cholangiopancreatography drainage failure.[1],[2],[3] However, malignant hilar biliary strictures may cause difficulties with drainage of the right liver.[4] With a novel stent, a 6-Fr slim delivery system, and keeping a slight gap around the guidewire,[5] a bilateral SEMS placement could be performed using the stent-in-stent approach under EUS-BD.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Poincloux L, Rouquetto O, Buc E, et al. Endoscopic ultrasound-guided biliary drainage after failed ERCP: Cumulative experimente of 101 procedures at a single center. Endoscopy 2015;47:794-801.  Back to cited text no. 1
    
2.
Prachayakul V, Aswakul P. Endoscopic ultrasound-guided biliary drainage: Bilateral systems drainage via left duct approach. World J Gastroenterol 2015;21:10045-8.  Back to cited text no. 2
    
3.
Nakai Y, Kogure H, Isayama H, et al. Endoscopic ultrasound-guided biliary drainage for unresectable hilar malignant biliary obstruction. Clin Endosc 2019;52:220-5.  Back to cited text no. 3
    
4.
Caillol F, Rouy M, Pesenti C, et al. Drainage of the right liver using EUS guidance. Endosc Ultrasound 2019;8:S50-S56.  Back to cited text no. 4
    
5.
Takenaka M, Nakai A, Kudo M. Novel concept of bared type metallic stent for endoscopic bilateral stent-in-stent placement in patients with hilar malignant biliary obstruction (with video). J Hepatobiliary Pancreat Sci 2020;27:282-3.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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