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DOI: 10.1055/s-0042-124499
Balloon enteroscopy-assisted biliary drainage using a diathermic dilator followed by placement of a novel ultra-slim metallic stent
Corresponding author
Publikationsverlauf
Publikationsdatum:
31. Januar 2017 (online)
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]).
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0042-124499-i0004cl1.jpg)
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Qualität:
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]).
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0042-124499-i0004cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
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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
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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.
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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
Corresponding author
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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
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0042-124499-i0004cl1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0042-124499-i0004cl2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0042-124499-i0004cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0042-124499-i0004cl4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)