Balloon enteroscopy-assisted biliary drainage using a diathermic dilator followed by placement of a novel ultra-slim metallic stent

Endoscopic management of malignant biliary stricture after hepaticojejunostomy is challenging. Although balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) has been developed, dedicated devices are still insufficient. We present a case of successful enteroscopic dilation using a wire-guided diathermic dilator [1] [2] [3] [4] [5], and placement of a novel, ultra-slim, uncovered, self-expandable, metallic stent (USEMS) for the treatment of a severe malignant stricture of the perihilar bile duct after hepaticojejunostomy.

A 52-year-old man with obstructive jaundice was referred to our department. He had undergone pancreaticoduodenectomy with hepaticojejunostomy for pancreatic head cancer 27 months earlier. He had received 6 months of chemotherapy for multiple liver metastases, but this treatment was suspended because of multiple liver abscesses, which developed 1 month before we saw him.

Computed tomography revealed intrahepatic bile duct dilation, perihilar biliary mass, and ascites. Double-balloon enteroscopy (EI-530B; Fujifilm Corp., Tokyo, Japan) was selected for biliary drainage. Double-balloon enteroscopy showed jejunal invasion of recurrent tumor involving the hepaticojejunal anastomosis ([Fig. 1 a, b]). A tapered ERCP catheter and a 0.025-inch guidewire were passed through the stricture of the hepaticojejunal anastomosis ([Fig. 1 b]). ERCP showed perihilar biliary stricture ([Fig. 2 a], [Video 1]), which could not be passed by the tapered ERCP catheter ([Video 1]).

Fig. 1 Endoscopic images. a Jejunal invasion. b Edematous mucosa around the hepaticojejunal anastomosis.

Fig. 2 Radiographic images. a Perihilar biliary stricture. b Wire-guided diathermic dilator passing the perihilar bile duct stricture (inset: 6 Fr wire-guided diathermic dilator insertion under endoscopic guidance).

Video 1: Wire-guided diathermic dilation after failed dilation using a tapered endoscopic retrograde cholangiopancreatography catheter, and deployment of novel, ultra-slim, uncovered, self-expandable, metallic stents.

The severe stricture was dilated successfully with a wire-guided diathermic dilator (Cysto-Gastro-Set, 6 Fr, length 180 cm; Endo-Flex, Voerde, Germany) ([Fig. 2 b], [Video 1]). Total dilation time was 3 seconds for the hepaticojejunal anastomosis and 13 seconds for the perihilar biliary stricture, respectively. A slim USEMS (Zilver 635, 6.0 Fr delivery system, 10 mm diameter, 200 cm long; Cook Japan, Tokyo, Japan) failed to pass the stricture. However, a novel ultra-slim USEMS (BileRush Selective, 5.7 Fr delivery system, 10 mm diameter, 185 cm long; Piolax Medical Devices, Kanagawa, Japan) was successfully deployed, followed by placement of an additional USEMS, in a stent-in-stent fashion, without any complications ([Fig. 3], [Fig. 4], [Video 1]).

Fig. 3 Comparison of a novel, ultra-slim, uncovered, self-expandable, metallic stent (USEMS; BileRush Selective, 5.7 Fr delivery system, 10 mm diameter, 185 cm long; PIOLAX Medical Devices, Kanagawa, Japan) (above), and a slim USEMS (Zilver 635, 6.0 Fr delivery system, 10 mm diameter, 200 cm long; Cook Japan, Tokyo, Japan) (below).

Fig. 4 Radiograph showing deployed novel ultra-slim uncovered self-expandable metallic stent (inset: enteroscopic view).

In summary, using balloon enteroscopy, a wire-guided diathermic dilator and novel ultra-slim USEMS were useful in facilitating dilation and stenting for the treatment of severe malignant anastomotic and biliary strictures in a patient with altered anatomy.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests

Dr. Kawakami has collaborated with Piolax Medical Devices on the development of the BileRush Selective, and is a consultant and gives lectures for the company.

• References

• 1 Kawakami H, Kuwatani M, Eto K. et al. Resolution of a refractory severe biliary stricture using a diathermic sheath. Endoscopy 2012; 44 (Suppl. 02) E119-120
• 2 Kawakami H, Kuwatani M, Kawakubo K. et al. Transpapillary dilation of refractory severe biliary stricture or main pancreatic duct by using a wire-guided diathermic dilator (with video). Gastrointest Endosc 2014; 79: 338-343
• 3 Kawakami H, Kuwatani M, Sakamoto N. Endoscopic ultrasound-guided antegrade diathermic dilation followed by self-expandable metallic stent placement for anastomotic stricture after hepaticojejunostomy (with video). Dig Endosc 2014; 26: 121-122
• 4 Kawakami H, Kuwatani M, Kawakubo K. et al. Endoscopic ultrasound-guided antegrade diathermic dilation followed by self-expandable metal stent placement for malignant distal biliary stricture. Endoscopy 2014; 46 (Suppl. 01) E328-329
• 5 Kawakami H, Abo D, Kawakubo K. et al. Rendezvous biliary recanalization combining percutaneous and endoscopic techniques using a diathermic dilator for bile duct obstruction. Endoscopy 2014; 46 (Suppl. 01) E460-461