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.

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.

Competing interests

The authors declare that they have no conflict of interest.

• References

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• 2 Inoue T, Ibusuki M, Kitano R. et al. Combined side-by-side and stent-in-stent method for triple metal stenting in patients with malignant hilar biliary obstruction. Dig Endosc 2019; 31: 698-705
• 3 Yoshida M, Naitoh I, Hayashi K. et al. Various innovative roles for 3-Fr microcatheters in pancreaticobiliary endoscopy [published online ahead of print, 2021 Oct 30]. Dig Endosc 2021; DOI: 10.1111/den.14181.
• 4 Ban T, Kawakami H, Kubota Y. et al. Endoscopic ultrasonography-guided fine-needle biopsy from the pancreatic head of a patient with Roux-en-Y reconstruction. Endoscopy 2018; 50: E202-E204
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Publication History

Article published online:
15 July 2022