Combined stent-by-stent and stent-in-stent biliary metal stent deployment using a forward-oblique viewing echoendoscope in surgically altered anatomy

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.

Download video file ^{(24.1MB, mp4)}

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.