Case of endoscopic bilateral stent-in-stent placement using long metallic stents for pancreatic cancer and plexus invasion.

BRIEF EXPLANATION

A 75‐year‐old man presented with obstructive jaundice due to pancreatic cancer (Fig. 1). He had a long malignant biliary obstruction consisting of two stenoses: one in the distal bile duct caused by pancreatic cancer and the other (type 2 according to the Bismuth classification) caused by plexus invasion along the gastroduodenal artery to the right hepatic artery. First, bilateral endoscopic drainage was performed using two plastic stents. However, their patency was short. We then attempted partial stent‐in‐stent (pSIS) placement using a long stent (Zilver635; Cook Medical Endoscopy, Winston‐Salem, NC, USA). Two guidewires were advanced into the left and anterior branch of the right hepatic duct. On fluoroscopic imaging, the first stent (diameter, 8 mm; length, 12 cm) was inserted into the left bile duct across the ampulla of Vater. Next, a contrast catheter was advanced with a guidewire passed through the stent cell. The second stent (diameter, 8 mm; length, 10 cm) was easily placed through the mesh from the anterior branch of the right hepatic duct to above the ampulla (Fig. 2, Video S1). Bilateral metallic stenting can be achieved by pSIS or side‐by‐side (SBS) methods. While technically challenging, the safety and efficacy of this approach has been demonstrated. , We selected pSIS because it showed superior technical feasibility or patency than SBS by referring to the meta‐analysis. , Most metallic stents used in pSIS are 6–8 cm in length. We occasionally experience cases of long malignant biliary obstruction, requiring three metallic stents: one for the distal bile duct and two for the hilar bile duct obstruction. In this case, two long metallic stents were sufficient. With this approach, cost reduction can be expected. A long metallic stent may be useful for pSIS placement in cases involving malignant biliary obstruction from the distal bile duct to the hilar bile duct.

Figure 1

(Upper left) Contrast‐enhanced computed tomography (CE‐CT) showing pancreatic head cancer (arrowheads). (Upper right) Magnetic resonance cholangiopancreatography showed a long malignant biliary obstruction from the distal bile duct (arrowheads, yellow) to the hilar bile duct (arrows) and pancreatic duct stenosis (arrowhead, red). (Lower left and right) CE‐CT showed wall thickening of the common bile duct (arrowheads) and a low‐density area around the right hepatic artery (arrows).

Figure 2

Partial stent‐in‐stent method for malignant biliary obstruction from the distal bile duct to the hilar bile duct. The length of each stent was determined by measuring from the intact intrahepatic bile duct to the duodenum or into the first stent.

Authors declare no conflict of interest for this article.

Video S1 The long metallic stents were successfully placed by partial stent‐in‐stent for malignant biliary obstruction from the distal bile duct to the hilar bile duct due to pancreatic cancer and plexus invasion.

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