Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Abstract

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.

Keywords: bilateral biliary drainage; hilar malignant biliary obstruction; self-expandable metallic stent.

Figure 1.

Image findings and the diagnosis. A: A gallbladder tumor with common bile duct invasion was observed in contrast-enhanced CT (arrows). B: Common bile duct stricture was seen during ERC. A biliary ductal biopsy was performed. C: The biliary biopsy specimen was diagnosed as adenocarcinoma. Fibrosis was observed in the overall specimen. The tumor cells had irregular tubular structures and invasive proliferation. CT: computed tomography, ERC: endoscopic retrograde cholangiography

Figure 2.

The state of biliary stricture and treatment. A: The hepatic ducts were divided into four branches (left, B6, B7, right anterior) by cancer. The black line represents the border between B7 and the right anterior hepatic duct. B: The Niti-S large cell stent D type 10 mm×10 cm (Taewoong Medical) was inserted in the left hepatic duct. The same stent (10 mm×8 cm) was inserted in B6. The new Niti-cell large cell stent with a slim delivery system (Taewoong Medical) was inserted into the right anterior hepatic duct. C: Approximately one week after the three SEMSs had been inserted, dilated B7 and a liver abscess (arrow) were observed on CT. D: ERC was performed, and the guidewire and ERC catheter were inserted in B7. E: Finally, four SEMSs were placed. F: Forty-three days after the four SEMSs had been inserted, improvement of the liver abscess was seen (arrow). All SEMSs were placed in a stent-in-stent fashion. B: The bile duct branch of the segment, SEMS: self-expandable metallic stent, CT: computed tomography, ERC: endoscopic retrograde cholangiography

Figure 3.

The new SEMS with a slim delivery system. The Figures were supplied by Century Medical (Tokyo, Japan). A: The Niti-S large cell stent slim delivery (Taewoong Medical) with a 6-Fr delivery system. The delivery system of the conventional Niti-S large cell D type stent (Taewoong Medical) was 8 Fr. B: The 6-Fr delivery system has good trackability to the guidewire. C, D: At the tip of the 6-Fr delivery system, the step between the delivery system and guidewire becomes lower than that of the delivery system of the conventional 8-Fr delivery system. SEMS: self-expandable metallic stent