Multiple metal stenting using a double-balloon endoscope for malignant biliary obstruction in a patient with hepaticojejunostomy.

Endoscopic management of malignant biliary obstruction following hepaticojejunostomy can be challenging. With the advent of the short double-balloon endoscope (DBE), therapeutic biliary interventions are possible in surgically altered anatomy [1,2]. Additionally, a novel uncoveredmetal stent (UMS) has been developed with a 200-cm-long, 6-Fr delivery system (Zilver 635; Cook Medical, Winston-Salem, North Carolina, United States) to enable metal stent placement using a short DBE [3]. We present a successful case of multiple metal stenting using a short DBE and UMS for malignant biliary obstruction after hepaticojejunostomy. A 75-year-old man with extrahepatic bile duct cancer underwent pancreaticoduodenectomy with Roux-en-Y reconstruction. He developed cholangitis 11 months postoperatively as a result of liver metastasis in the medial left lobe segment. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to place two plastic stents using a short DBE (EI-530B; Fujifilm Corp., Tokyo, Japan). However, rapid tumor growth resulted in recurrent episodes of cholangitis. Therefore, the decision was made to insert multiple metal stents via another ERCP using the short DBE. The plastic stents were removed, and the hepaticojejunostomy anastomosis was Fig.3 The second uncovered metal stent (UMS) was deployed through the mesh of the initial UMS. Fig.1 The first uncovered metal stent was deployed into the anterior branch of the right hepatic duct.