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Efficacy and Long-Term Outcomes of Side-by-Side Self-Expandable Metal Stent Placement Using a 2-Channel Endoscope for Unresectable Malignant Hilar Biliary Obstruction Occurring After Billroth II Reconstruction (with Video)

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Abstract

Background

Long-term studies evaluating self-expandable metal stents in patients who have unresectable malignant hilar biliary obstruction (UMHBO) after surgical reconstruction of the intestine remain inadequate. We developed a side-by-side (SBS) technique using a two-channel endoscope to place self-expandable metal stents in patients with UMHBO occurring after Billroth II reconstruction.

Aims

We validated the long-term outcomes obtained with this technique.

Methods

The study group comprised seven patients with UMHBO in whom we attempted to place metal stents by the SBS technique using a two-channel scope. The procedure was validated retrospectively.

Results

The technical success rate was 86% and functional success rate was 100%. The median time to recurrent biliary obstruction (RBO) was 222 days (95% CI 4.9–439.1). Besides RBO, there were no other complications.

Conclusions

The SBS procedure performed using a two-channel scope is a safe and useful new technique for the treatment of UMHBO occurring after Billroth II reconstruction.

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Fig. 1

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Author information

Correspondence to Kosuke Okuwaki.

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Conflict of interest

The authors declared that they have no conflict of interest.

Electronic supplementary material

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Video 1. Patient 1 had hilar malignant stricture caused by recurrent metastases of gallbladder cancer to the liver (Bismuth IV, Billroth-II gastrectomy without Braun anastomosis). Cholangiography showed a Bismuth type IV stricture. Guide wires were placed in the B6 and B5 bile ducts. Because contrast media flowed into the B2 and B3 bile ducts, a guide wire was placed in the B2 bile duct, and a 5-French endoscopic nasobiliary drainage tube was placed in the B2 bile duct. Subsequently, 60-mm Zilver 635® self-expanding biliary stents were placed in the right anterior segmental branch and the right posterior segmental branch of the liver. (MP4 228856 kb)

Video 2. Patient 4 had hilar malignant stricture caused by hilar lymph node metastasis after surgery for pancreatic head cancer (Bismuth IIIa, pylorus-preserving pancreatoduodenectomy with Braun anastomosis). Cholangiography showed a Bismuth type IIIa stricture. Guide wires were placed in the B2 and B8 bile ducts. An 80-mm Zilver 635® self-expanding biliary stent was placed in the B2 bile duct, and a 60-mm Zilver 635® self-expanding biliary stent was placed in the right anterior segmental branch. (MP4 111570 kb)

Video 3. Patient 5 had malignant strictures at the hilum of the liver and the jejunum caused by hilar lymph node recurrence after surgery for pancreatic head cancer. Percutaneous transhepatic biliary drainage (PTBD) was performed using the rendezvous technique, allowing successful bile duct cannulation. A 45-mm stricture was found in the jejunum. A 60-mm Niti-S™ pyloric/duodenal D-type stent was placed in the jejunal stricture. Subsequently, guide wires were placed in the B8 and B3 bile ducts using a Haber RAMP™ catheter (Cook Medical). A 60-mm Zilver 635® self-expanding biliary stent was placed in the left and right hepatic ducts along with a duodenal stent. Confirmation imaging from the PTBD showed the flow of contrast media. (MP4 105407 kb)

Video 1. Patient 1 had hilar malignant stricture caused by recurrent metastases of gallbladder cancer to the liver (Bismuth IV, Billroth-II gastrectomy without Braun anastomosis). Cholangiography showed a Bismuth type IV stricture. Guide wires were placed in the B6 and B5 bile ducts. Because contrast media flowed into the B2 and B3 bile ducts, a guide wire was placed in the B2 bile duct, and a 5-French endoscopic nasobiliary drainage tube was placed in the B2 bile duct. Subsequently, 60-mm Zilver 635® self-expanding biliary stents were placed in the right anterior segmental branch and the right posterior segmental branch of the liver. (MP4 228856 kb)

Video 2. Patient 4 had hilar malignant stricture caused by hilar lymph node metastasis after surgery for pancreatic head cancer (Bismuth IIIa, pylorus-preserving pancreatoduodenectomy with Braun anastomosis). Cholangiography showed a Bismuth type IIIa stricture. Guide wires were placed in the B2 and B8 bile ducts. An 80-mm Zilver 635® self-expanding biliary stent was placed in the B2 bile duct, and a 60-mm Zilver 635® self-expanding biliary stent was placed in the right anterior segmental branch. (MP4 111570 kb)

Video 3. Patient 5 had malignant strictures at the hilum of the liver and the jejunum caused by hilar lymph node recurrence after surgery for pancreatic head cancer. Percutaneous transhepatic biliary drainage (PTBD) was performed using the rendezvous technique, allowing successful bile duct cannulation. A 45-mm stricture was found in the jejunum. A 60-mm Niti-S™ pyloric/duodenal D-type stent was placed in the jejunal stricture. Subsequently, guide wires were placed in the B8 and B3 bile ducts using a Haber RAMP™ catheter (Cook Medical). A 60-mm Zilver 635® self-expanding biliary stent was placed in the left and right hepatic ducts along with a duodenal stent. Confirmation imaging from the PTBD showed the flow of contrast media. (MP4 105407 kb)

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Okuwaki, K., Yamauchi, H., Kida, M. et al. Efficacy and Long-Term Outcomes of Side-by-Side Self-Expandable Metal Stent Placement Using a 2-Channel Endoscope for Unresectable Malignant Hilar Biliary Obstruction Occurring After Billroth II Reconstruction (with Video). Dig Dis Sci 63, 1641–1646 (2018). https://doi.org/10.1007/s10620-018-5013-8

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Keywords

  • ERCP
  • Malignant hilar biliary obstruction
  • Billroth II
  • Side-by-side
  • Two-channel endoscope
  • Self-expandable metal stent