Sequential double stent placement using the stent-pushing-stent technique over a single wire during double-balloon ERCP

Double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is now an established technique to perform various types of diagnostic and therapeutic interventions in patients with surgically altered upper gastrointestinal anatomy [1]. Herein, we present a novel and simple technique of dual stenting using the stent-pushing-stent technique.

A 45-year-old patient who had undergone liver transplant for cirrhosis due to primary sclerosing cholangitis 8 years previously presented with jaundice and cholestasis. Because of primary sclerosing cholangitis, the liver transplant was attached to a jejunal loop (hepaticojejunostomy). Therefore, ERCP had to be performed using DBE.

During DBE-ERCP, a tight hepaticojejunostomy stricture was found and classified as type A1 according to Mönkemüller–Jovanovic classification [2]. The stricture was dilated with a 6-mm-diameter controlled radial expansion balloon ([Video 1]). Insertion of plastic stents was indicated to keep the stenosis open and allow for proper fibrotic remodeling around the hepaticojejunostomy, and thus reduce the chances of re-stenosis.

Video 1 Sequential double stent placement using the stent-pushing-stent technique over a single wire during double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography.

We used a novel stent-pushing-stent technique ([Fig. 1], [Video 1]). The two plastic stents were placed using a single 0.035-inch biliary wire 450 cm in length. This technique shortens the procedure time and is useful when using device-assisted ERCP methods. The stents are advanced over the wire, one after the other; the pusher tube is used to push the proximal stent, which in turn pushes the distal stent. Once the first stent has been deployed, the wire is carefully retrieved, and then used to perform direct cannulation of the bile duct, next to the first stent. Once deep wire insertion is achieved, the second stent is deployed in the desired location.

Fig. 1 The stent-pushing-stent technique. The stents are advanced over the wire, one after the other. The long arrow shows the first stent and the short arrow shows the second, “pushing” stent. A pusher tube is used to push the proximal stent, which in turn pushes the distal stent.

This technique is ideal during ERCP with forward-viewing endoscopes, especially in the presence of hepaticojejunostomy and difficult postoperative anatomy, as it is practical and time saving.

Endoscopy_UCTN_Code_CPL_1AK_2AD

^* These authors contributed equally to this work.

Publication History

Article published online:
11 April 2022

• References

• 1 Skinner M, Popa D, Neumann H. et al. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 2014; 46: 560-572
• 2 Mönkemüller K, Jovanovic I. Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: a practical classification. World J Gastrointest Endosc 2011; 16: 213-219