Double-guidewire technique using a novel ERCP cannula for hepatic hilar obstruction.

Endoscopic biliary drainage (EBD) for hepatic hilar obstruction is sometimes challenging. Moreover, when unilateral biliary drainage has already been performed, if another intrahepatic bile duct also needs to be drained, EBDmay be mademore difficult because of tumor ingrowth and the narrowed angle from which the bile duct must be accessed. In this case, percutaneous biliary drainage (PTBD) or endoscopic ultrasound-guided biliary drainage (EUS-BD), especially EUS-guided hepaticogastrostomy (EUS-HGS), may be indicated. However, PTBD is known to be associated with several adverse events such as cholangitis, biliary leakage, and pneumothorax [1], and EUS-HGS is associated with adverse events such as bile peritonitis, cholangitis, and potentially fatal stent dysfunction [2]. It appears that EBD may be more feasible compared with these other salvage techniques. Recently, a novel endoscopic retrograde cholangiopancreatography (ERCP) cannula with an uneven double lumen has been made available (Piolax Medical Devices, Kanagawa, Japan) (●" Fig.1). Herein, we present a “double-guidewire technique” using this novel ERCP cannula for hepatic hilar obstruction. A 45-year-old man was referred to our hospital with obstructive jaundice due to left intrahepatic bile duct obstruction. He had undergone EBD 6 months previously for relief of obstructive jaundice caused by pancreatic cancer with an uncovered metal stent being placed between the right hepatic duct and the common bile duct and a fully covered metal stent being placed between the upper and lower bile ducts. We decided that he would need reintervention to treat the obstructed left intrahepatic bile duct. Firstly, we inserted a standard ERCP cannula (MTW Endoscopy, Düsseldorf, Germany) into the previously placed metal stent and injected contrast medium, which confirmed the left intrahepatic bile duct obstruction (●" Fig.2a). An attempt was thenmade to pass a 0.025-inch guidewire (VisiGlide; Olympus Medical Systems, Tokyo, Japan) through the left intrahepatic bile duct obstruction, but this was unsuccessful. We therefore changed the cannula to the new uneven double-lumen cannula, advancing this first into the right intrahepatic bile duct with a guidewire through the 0.025-inch guidewire lumen. The cannula was then slowly withdrawn while we probed for the left intrahepatic bile duct using a guidewire (Cheer Leader+M, angle type; Tri-Med Co. Ltd., Osaka, Japan) via the 0.035-inch lumen and we were able to successfully advance the guidewire through the left intrahepatic bile duct obstruction (●" Fig.2b; ●" Video1). Finally, once the guidewire had been placed in the left intrahepatic duct, we inserted an uncovered metal stent between the left intrahepatic duct and the common bile duct (●" Fig.2c). No complications were observed, and the jaundice resolved Fig.1 The uneven double-lumen cannula with a 0.025-inch guidewire lumen (yellow arrow) and a 0.035-inch guidewire lumen (red arrow).