An Effortless Collision Sport in the Bile Duct - A Novel Stent Delivery System for Malignant Biliary Hilar Obstruction

Abstract

INTRODUCTION For malignant hilar biliary obstructions (MHBOs), self-expanding metal stents (SEMS) provide superior patency, decreased number of interventions and cost effectiveness. Nevertheless, an accurate and smooth bilateral metal stent deployment in this setting has been a technical challenge. We present our experience of a novel laser cut bilateral biliary stent with dual deployment method delivery system in a case of MHBO. CASE PRESENTATION A 53-year-old male with history of colon cancer, status post left hemicolectomy and chemotherapy with distant metastasis to liver, mediastinum, presented with signs and symptoms of biliary obstruction. ERCP revealed a previously placed biliary uncovered self-expandable metal stent (USEMS) in common bile duct with near total occlusion extending up to hilum and severe upstream dilation of both right and left hepatic ducts and their branches. The metal stent was cleaned with stone extraction balloon and a 10F by 5cm double-pigtail plastic biliary stent was placed. A week later, ERCP with bilateral SEMS placement was arranged for long term therapy of MHBOs (secondary to metastatic disease burden). Two (10cm by 6mm) uncovered laser cut bilateral biliary stent with dual deployment method delivery system were chosen. Under fluoroscopic imaging, two separate preferred stent deployment devises were advanced over the guidewire simultaneously, traversing through the USEMS in CBD in right and left intrahepatic ducts followed by simultaneous stent release by the technician using the unique thumb wheel deployment in side by side stent placement fashion successfully with excellent contrast and bile flow. Follow up total bilirubin was 1 mg/dL with symptom resolution.1413_A.tif Figure 1: Fluoroscopy image of a previously placed metal stent and dilated intrahepatic biliary ductDISCUSSION: Biliary stent treatment for MHBOs carries increased risk of complications if placement fails. MHBOs drainage can be achieved by “side-by-side” (SBS) or the “stent-in-stent” (SIS) techniques. The SBS technique carries risk of impaction of the distal ends of first SEMS during the second SEMS delivery. SIS technique can be difficult during guidewire cannulation to desired contralateral duct through the preexisting SEMS. This novel laser cut bilateral biliary stent with dual deployment system provides stent flexibility and thumbwheel deployment option with auditory indicators and tactile feedback conveys better control and accuracy for simultaneous deployment. 6F stent catheter decreases risk of stent impaction during the same.1413_B.tif Figure 2: Fluoroscopy image of Epic stents1413_C.tif Figure 3: CT image of the Epic stents