Management of obstructive cholangiocarcinoma with metallic stents, implanted in a Y-shaped pattern, in one session

Most patients with unresectable, malignant, obstructive, cholangiocarcinoma are candidates for palliation. Biliary drainage by endoscopic interventions (ERCP), with implantation of self-expandable metallic stents (SEMSs), plays a major role in improving liver function and managing or avoiding cholangitis [1]. We present two cases (a 78-year-old man and a 65-year-old woman) with advanced, unresectable, cholangiocarcinoma (Bismuth, Type IV). They were treated with, a ̈one-step ̈ implantation of SEMSs (Wallstent stents – Uncovered Nitilol stents), by ERCP, in a Y-shaped pattern. The biliary decompression was successful and significant reduction in jaundice was achieved, in both cases. The male patient had bilateral hilar strictures in both the right and left hepatic duct, in the common hepatic duct and in the middle of the common bile duct (Fig. 1A). Endoscopic sphincterotomy and balloon dilatation (distal stenosis) were performed. Then we inserted an uncovered SEMS 8 cm (with window) in the left hepatic bile duct and a second uncovered SEMS 10 cm (intact gallbladder) in the right hepatic bile duct and in the common bile duct, through the first SEMS (Fig. 1B). The total serum bilirubin level (TSBL) dropped from a mean of 27 mg/dL to 2.5 mg/dL, within the first 20 days. The female patient had an inoperable cholangiocarcinoma that involved the confluence and both (right and left) hepatic bile ducts (Fig. 1C). We inserted an uncovered SEMS 10 cm (with window) in the right hepatic bile duct and a second uncovered SEMS 10 cm in the left hepatic bile duct and in the common bile duct, through the first SEMS (Fig. 1D). The TSBL dropped (13.5 mg/dL to 1.5 mg/dL), within the first 5 days. The use of unilateral or bilateral SEMSs, in patients with unresectable malignant obstructive cholangiocarcinoma, is debatable [1-5]. In some cases, the placement of unilateral SEMSs is adequate, because only 30% of the liver needs to be drained in order to reduce jaundice [3]. Inversely, uni-