The feasibility and safety of endoscopic deployment of multiple
metallic stents in malignant hilar biliary strictures have been addressed in
several articles [1]
[2]
[3]
[4]
[5].
However, once metallic stents are occluded, multiple deployment of plastic
stents through the previously deployed metallic stents is sometimes difficult.
We have designed a new plastic stent for dealing with multiple metallic stent
occlusion, and report a successful case using this new stent.
A 64-year-old man with obstructive jaundice was referred to our
hospital. He had malignant hilar biliary strictures caused by pancreatic cancer
([Fig. 1]).
Fig. 1 The patient had a
Bismuth-type stricture resulting from invasion by pancreatic cancer.
We used a Zeostent (Zeon Medical, Tokyo, Japan) and deployed
three-branched metallic stents using a partial stent-in-stent procedure ([Fig. 2]) following administration of gemcitabine.
Fig. 2 Deployment of three
metallic stents into the left hepatic duct and the posterior and anterior
branches of the right hepatic duct.
Three months after chemotherapy, the patient was readmitted to our
hospital with fever and elevated serum biliary enzymes. Endoscopic retrograde
cholangiography revealed occlusion of the metallic stents with a filling defect
([Fig. 3]).
Fig. 3 Occlusion of the
metallic stents because of tissue ingrowth.
We used a newly designed plastic stent (Through The Mesh stent
[TTM stent], Cathex, Tokyo, Japan), 7 Fr in diameter with a
distal tapered hook tip and a proximal pigtail-shaped end ([Fig. 4]).
Fig. 4 The Through The Mesh
(TTM) stent is available in three lengths (19, 21, and 22 cm).
The length and taper of the hooked distal end of the TTM stent are
shorter and narrower, respectively, than those of the 7-Fr Zimmon-type plastic
stent (Wilson-Cook Medical Inc., Winston-Salem, North Carolina, USA) ([Fig. 5])
and facilitate the tip’s entry into the proximal bile duct through the
previously deployed metallic stents without getting caught in the stricture and
the interstices of the metallic stents.
Fig. 5 The Through The Mesh
(TTM) stent and a Zimmon-type stent mounted over the guide wire.
We negotiated each stent’s lumen with a guide wire following
successful deployment of three TTM stents ([Fig. 6]).
Fig. 6 Deployment of the three
plastic stents into the left hepatic duct and the posterior and the anterior
branches of the right hepatic duct.
The patient’s fever resolved, and the bilirubin level
decreased from 4.11 mg/dL to 0.79 mg/dL. The patient was
discharged and chemotherapy resumed.
We believe that this newly designed plastic stent will be useful for
biliary decompression following occlusion of multiple metallic stents deployed
in malignant hilar biliary strictures.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
