Use of a temporary plastic stent to facilitate the placement of multiple self-expanding metal stents in malignant biliary hilar strictures

Abstract

Although endoscopic palliation of malignant biliary hilar obstruction is preferable to surgery or percutaneous drainage, it remains technically challenging. This is especially true when multiple self-expanding metal stents (SEMS) are placed, because difficulty is commonly encountered in passing the second SEMS at the level of the previously deployed initial stent. We have devised a method of deploying multiple metal stents by using a temporary plastic stent, which makes deployment of the second stent much easier. After guidewire placement, a plastic stent is deployed in a subhilar position. The initial SEMS is deployed, with the plastic stent maintaining a passage for the second SEMS. After the second SEMS is deployed, the plastic stent is retrieved. This technique has been used successfully in 7/8 patients, all of whom presented with symptomatic jaundice secondary to malignant hilar obstruction of various etiologies (cholangiocarcinoma, n=4; metastatic disease, n=3; and hepatocellular carcinoma, n=1). Drainage was successful in all cases, with significant improvement in symptoms and cholestasis. This simple technique lessens the technical difficulty of placing bilateral hilar SEMS.