EUS-guided bridging stent placement using a new slim-delivery system for malignant hilar biliary obstruction: Two case reports (with video)

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Malignant hilar biliary obstruction (MHBO) can cause cholangitis in the right and left intrahepatic bile ducts (IHBDs) and requires bilateral drainage. Although transpapillary bilateral drainage is the gold standard treatment for MHBO, EUS-guided hepaticogastrostomy (EUS-HGS) is an effective alternative treatment when the transpapillary approach is difficult. Additionally, stent placement in MHBO during EUS-HGS allows for bridging bilateral IHBD drainage. Stent insertion is challenging when the hilar bile duct is sharply angulated (V-shaped) or severely obstructed. Case 1 This was a case of large pancreatic head cancer. Because of difficulty in transpapillary cannulation due to tumor invasion of the main papilla, EUS-HGS was performed. Cholangiography revealed MHBO and dilation of the IHBDs in both lobes. EUS-HGS first used a partially covered self-expandable metal stent (SEMS) in the left IHBD to improve jaundice, followed by cholangitis in the right IHBD. During reintervention via the EUS-HGS route, a 0.025-inch guidewire was placed into the right IHBD; however, the catheter could not pass through the MHBO. An uncovered SEMS with a new slim-delivery system (Niti-S Large Cell SR Slim Delivery; Taewoong Medical, Seoul, South Korea) smoothly passed the MHBO and achieved bridging drainage [Figure 1] (Video 1).Figure 1: Case 1 with a large pancreatic head cancer. A, Cholangiography shows MHBO and dilation of both the right and left IHBDs. B, EUS-HGS is performed to the left IHBD using a partially covered SEMS. C, Right IHBD cholangitis occurred after the procedure. D, Catheter could not pass through the MHBO (arrow). E, The new slim-delivery system smoothly passed the MHBO (arrowhead). F, Finally, SEMS could be placed in MHBO. MHBO, malignant hilar biliary obstruction; IHBD, intrahepatic bile duct; EUS-HGS, EUS-guided hepaticogastrostomy; SEMS, self-expandable metal stent.Case 2 This was a case of hilar cholangiocarcinoma. A bilateral plastic stent was routinely exchanged; however, a duodenoscope could not be inserted into the main papilla because of duodenal invasion. EUS-HGS was performed after plastic stent removal using a nasoendoscope. Cholangiography revealed an MHBO and a V-shaped hilar bile duct. Although a 0.025-inch guidewire could be inserted into the right IHBD, the catheter could not be passed. The new slim-delivery system could smoothly pass through the MHBO and achieve bridging drainage [Figure 2] (Video 1).Figure 2: Case 2 with hilar cholangiocarcinoma. A, Bilateral plastic stents have been routinely exchanged. B, The duodenoscope could not be inserted into the main papilla due to duodenal malignant obstruction. C, The catheter could not pass MHBO due to sharp angle (arrow). D, The new slim-delivery system smoothly passed through the MHBO (arrowhead). F Finally, SEMS could be placed in the MHBO. MHBO, malignant hilar biliary obstruction; IHBD, intrahepatic bile duct; SEMS, self-expandable metal stent.For the bridging technique, the stent was inserted from the left to right IHBD via the MHBO from the EUS-HGS route. Therefore, thin and supply functions are required for stent delivery systems. The new slim-delivery system has a tapered tip and 6F size, which was developed to easily perform stent-in-stent transpapillary bilateral SEMS placement.[1] This system is also useful as a bridging technique for passing tight MHBO and V-shaped hilar bile ducts. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Supplementary Videos","caption":"Video 1. Uncovered SEMS with the new slim-delivery system smoothly passed the MHBO via the EUS-HGS route and enabled effective biliary drainage, even when a conventional catheter could not pass. The video is only available at the official website of the journal (www.eusjournal.com).","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_gddbfwmr"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

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