Bilateral stent-in-stent placement of biliary metal stents with a slim delivery system through an ultraslim endoscope

A novel laser-cut-type uncovered self-expandable metal stent (UCSEMS) has recently become available in Japan (Yabusame; Kaneka Medical, Osaka, Japan) ¹ . The stent delivery system was 5.4 Fr, with an extremely tapered tip ( Fig. 1 ). Here, we describe bilateral stent-in-stent placement of the UCSEMS using an ultraslim endoscope for malignant hilar biliary obstruction with duodenal stenosis.

Fig. 1.

 The stent delivery system was only 5.4 Fr, with an extremely tapered tip.

A 79-year-old man underwent endoscopic sphincterotomy and transpapillary biliary drainage with two plastic stents for malignant hilar biliary stenosis caused by an unresectable gallbladder cancer. Six months later, acute cholangitis occurred due to stent occlusion. A duodenoscope could not reach the papilla because of malignant duodenal stenosis, and endoscopic ultrasound-guided hepaticogastrostomy and percutaneous transhepatic biliary drainage were difficult due to insufficient intrahepatic bile duct dilatation. Therefore, we attempted stent replacement using an ultraslim endoscope (GIF-1200N; Olympus, Tokyo, Japan). One of the two plastic stents had migrated into the common bile duct. The nonmigrated plastic stent was removed using biopsy forceps. The ultraslim endoscope was retroflexed to visualize the papilla ( Fig. 2 ) and directly inserted into the lower bile duct. Following insertion of a 0.025-inch guidewire into the right anterior hepatic duct, a slim stent delivery system of a novel UCSEMS (Yabusame) was inserted across the stricture through the ultraslim endoscope. The UCSEMS, 6 cm long and 8 mm in diameter, was deployed above the papilla under fluoroscopic and endoscopic guidance ( Fig. 3 ). The guidewire was inserted through the UCSEMS mesh into the left hepatic duct, and the slim stent delivery system of a second UCSEMS was successfully inserted. The second UCSEMS, also 6 cm long and 8 mm in diameter, was deployed above the papilla ( Fig. 4 ), and the migrated plastic stent was removed using biopsy forceps ( Video 1 ).

Fig. 2.

 Endoscopic image showing the papilla in the retroflex position of the ultraslim endoscope.

Fig. 3.

 The laser-cut-type uncovered self-expandable metal stent is placed above the papilla through the ultraslim endoscope: a fluoroscopic view, b endoscopic view.

Fig. 4.

 Stent-in-stent placement above the papilla is successfully performed: a fluoroscopic view, b endoscopic view.

Video 1  Bilateral stent-in-stent placement above the papilla using metal stents with a slim delivery system using an ultraslim endoscope.

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This technique may be a treatment option for malignant biliary obstruction with duodenal stenosis, in which a duodenoscope cannot reach the papilla.

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