Multiple Stenting in Hilar Bile Duct Carcinoma: Three-Branched Partial Stent-in-Stent Deployment with the JOSTENT SelfX

 

 Buy Article Permissions and Reprints

We read with great interest the paper by May et al., who reported the first preliminary results on treatment with the JOSTENT SelfX (Abbott Vascular Devices, Redwood City, California, USA), a new metallic stent for malignant biliary obstruction [1]. The article does not discuss the use of this metallic stent in the treatment of hilar biliary obstruction; we therefore decided to test a technique of triple partial stent-in-stent deployment using this device. The JOSTENT SelfX is very suitable for hilar malignant biliary obstruction.

A 78-year-old man with unresectable hilar bile duct carcinoma was admitted to our hospital (Figure [1]). Multiple stents were inserted endoscopically using the JOSTENT SelfX and Olympus TJF-240 (Olympus, Tokyo, Japan) instruments. Before stent insertion, the stenotic area of the biliary tract was dilated with a balloon dilator. The first stent was inserted into the left lateral segment, since the stent mesh space was widest at the branching. After the right posterior biliary branch had been located through the stent mesh using a Naviguide guide wire (Olympus, Tokyo, Japan), the second stent was inserted into this branch with a partial stent-in-stent procedure. Finally, the third stent was inserted into the right anterior biliary branch, also in a partial stent-in-stent manner (Figure [2]). At the time of writing, the patient was still showing no signs of stent occlusion after 6 months of follow-up.

Figure 1 Endoscopic cholangiogram in a 78-year-old man with hilar bile duct carcinoma. The stenosis extends from the common hepatic duct to both sides of the intrahepatic bile ducts.

Figure 2 Endoscopic deployment of the third JOSTENT SelfX. In the partial stent-in-stent technique, the ends of the metallic stents are inserted into the left lateral, right anterior, and right posterior segment of the liver through the involved bile ducts.

The use of metallic stents to drain both lobes of the liver rather than a single lobe is technically more difficult to achieve, particularly with endoscopic procedures [1] [2]. The partial stent-in-stent technique used represents a Y-shaped deployment of the metallic stents used to treat hilar bile duct stenosis. To achieve this type of deployment, a stenotic bile duct has to be located through the mesh of the metallic stent with a guide wire, after the deployment of the first stent. Next, the stent delivery device has to be pushed through the stent mesh and stenotic bile duct. Although this type of stent deployment is a difficult and challenging procedure, the JOSTENT SelfX provides a wide stent mesh, thin delivery shaft, and good pushability, making it a feasible method for endoscopic three-segment stent insertion.

There have been conflicting opinions in the literature regarding whether stent placement should be unilateral [3] [4] or bilateral [5] [6], and the issue has yet to be resolved. This new type of stent may now allow direct comparison of the outcomes between single and multiple stent insertion.

References

• 1 May A, Ell C. A new self-expanding nitinol stent (JOSTENT SelfX) for palliation of malignant biliary obstruction: a pilot study.  Endoscopy. 2004;  36 329-333
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Giovanni D, Palma D, Galloro G. et al . Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study.  Gastrointest Endosc. 2001;  53 547-553
  CrossrefPubMedGoogle Scholar
• 3 Peters R A, Williams S G, Lombard M. et al . The management of high-grade hilar strictures by endoscopic insertion of self-expanding metal endoprostheses.  Endoscopy. 1997;  29 10-16
  Article in Thieme ConnectPubMedGoogle Scholar
• 4 Freeman M L, Overby C. Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents.  Gastrointest Endosc. 2003;  58 41-49
  CrossrefPubMedGoogle Scholar
• 5 Chang W H, Kortan P, Haber G B. Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage.  Gastrointest Endosc. 1998;  47 354-362
  PubMedGoogle Scholar
• 6 Dumas R, Demuth N, Buckley M. et al . Endoscopic bilateral metal stent placement for malignant hilar stenoses: identification of optimal technique.  Gastrointest Endosc. 2000;  51 334-338
  CrossrefPubMedGoogle Scholar

H. Kawamoto, M. D.

Dept. of Gastroenterology and Hepatology
Okayama University Graduate School of Medicine and Dentistry

2-5-1 Shikata-cho
Okayama City, Okayama Prefecture 700-8558
Japan

Fax: + 81-86-225-5991

Email: h-kawamo@md.okayama-u.ac.jp