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A multi-hole self-expandable metallic stent (MHSEMS) with a thin 5.9-Fr delivery system and side-hole design supports multi-duct drainage while maintaining communication between biliary branches. An 86-year-old woman with Bismuth IV hilar obstruction underwent emergency ERCP with plastic stents, then definitive placement of three MHSEMSs via a new duodenoscope. Fluoroscopic deployment showed adequate expansion and effective drainage, potentially offering an alternative to multi-inside-stent strategies.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/den-open-case-report-simultaneous-placement-of-three-thin-delivery-multi-hole-self-expandable-metallic-stents-for-malignant-hilar-biliary-obstruction/444620/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/den-open-case-report-simultaneous-placement-of-three-thin-delivery-multi-hole-self-expandable-metallic-stents-for-malignant-hilar-biliary-obstruction/444620.png","ImageObject",300,407,{"name":92,"@type":93},"Kurz","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-04","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Why is simultaneous multi-duct drainage challenging in malignant hilar biliary obstruction?","Question",{"text":112,"@type":113},"Multiple stent insertions can be hindered by stent-stent interference, making it difficult to achieve and position adequate drainage in strictures involving three or more intrahepatic ducts.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What stent technology was used to facilitate drainage of multiple ducts?",{"text":117,"@type":113},"A multi-hole self-expandable metallic stent (MHSEMS) with a thin 5.9-Fr delivery system and side-hole design was used to support drainage of multiple ducts while preserving communication between biliary branches.",{"name":119,"@type":110,"acceptedAnswer":120},"How was the procedure performed in the reported case?",{"text":121,"@type":113},"After emergency ERCP with two temporary 5-Fr double-pigtail plastic stents, reintervention used a duodenoscope with a 4.5-mm working channel. Cholangiography confirmed three dilated hepatic ducts, and three MHSEMSs were inserted simultaneously and deployed under fluoroscopic guidance, achieving effective drainage.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},444620,1790742126,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":24,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":144,"preview_page_count":4},2336478945635,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","DEN Open  \nCASE REPORT   \nSimultaneous Placement of Three Thin-Delivery Multi-Hole Self-Expandable Metallic Stents for Malignant Hilar Biliary Obstruction Using a Large-Channel Duodenoscope  \nAkinobu Koiwai   Morihisa Hirota   Tomohiro Oikawa  Kei Ishikawa  Chihiro Yunomura  Takuro Nakaya  Takehito Itoh  Yuki Miyashita  Nana Inomata  Kennichi Satoh  \nDivision of Gastroenterology, Tohoku Medical and Pharmaceutical University, Miyagi, Japan Correspondence: Akinobu Koiwai ([a.koiwai@tohoku-mpu.ac.jp](a.koiwai@tohoku-mpu.ac.jp))  \nReceived: 10 November 2025  Revised: 18 December 2025  Accepted: 21 December 2025  \nKeywords: biliary drainage | duodenoscope | ERCP | self-expandable metal stent | side-by-side  \nABSTRACT  \nEndoscopic biliary drainage for malignant hilar biliary obstruction is technically demanding especially when multiple ducts require drainage. Plastic inside stents are widely used because of their removability and ease of exchange, but multiple insertion is often hindered by stent interference. Recently, a multi-hole self-expandable metallic stent (MHSEMS) with a thin 5.9-Fr delivery system and side-hole design has been developed to facilitate multi-duct drainage while maintaining communication between biliary branches. An 86-year-old woman presented with fever and vomiting. Laboratory data showed severe inflammation and mild cholestasis. Non-contrast computed tomography and magnetic resonance cholangiopancreatography revealed Bismuth IV hilar obstruction. Emergency endoscopic retrograde cholangiopancreatography achieved drainage by placing two 5-Fr doublepigtail plastic stents into the right anterior and left ducts. After improvement, reintervention was performed using a new duodenoscope (ED-840T; FUJIFILM, Tokyo, Japan) with a 4.5-mm working channel. Cholangiography confirmed dilatation of three hepatic ducts. Three MHSEMSs were inserted simultaneously through their thin 5.9-Fr delivery systems and deployed under fluoroscopic guidance. All stents expanded adequately, achieving effective drainage. This approach may represent an alternative to multi-inside-stent placement, overcoming the technical limitations of stent interference.  \n1  Introduction  \nEndoscopic biliary drainage is the preferred first-line treatment for malignant biliary obstruction (MHBO) . However, achieving adequate drainage in Bismuth type III-IV strictures remains technically demanding. The choice between a plastic inside stent (IS) and a self-expandable metallic stent (SEMS) depends on the patient’s condition, expected survival, and procedural feasibility [1, 2] .  \nISs are widely used because they avoid the duodenobiliary reflex and can be easily replaced when occluded. However, when  \nmultiple ISs are required, stent-stent interference often makes insertion and positioning difficult, especially in cases involving three or more intrahepatic ducts.  \nIn contrast, SEMS−particularly covered types−provided longer patency and larger luminal diameter but are more challenging to place in the hilar region. Recently, a multi-hole SEMS (MHSEMS, HANAROSTENT Biliary Multi Hole Benefit; Boston Scientific, MA, USA, Figure S1A) has been developed. This novel stent incorporates multiple small side holes in the covered membrane to maintain communication between biliary branches and prevent segmental isolation [3] . Its thin 5.9-Fr delivery system also  \nThis is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.  \n© 2026 The Author(s). DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.  \nDEN Open, 2026; 6:e70271  \n[https://doi.org/10.1002/deo2.70271](https://doi.org/10.1002/deo2.70271)  \n1 of 5  \nFIGURE 1  Non-contrast CT showing wall thickening of the hilar bile duct and dilatation of the intrahepatic bile ducts. MRCP demonstrating dilated intrahepatic bile d","cbCait1weUZk0hto","https://ap.wps.com/l/cbCait1weUZk0hto","pdf",1046778,"English","# ABSTRACT\n# 1 Introduction\n# 2 Case Report","[{\"question\":\"Why is simultaneous multi-duct drainage challenging in malignant hilar biliary obstruction?\",\"answer\":\"Multiple stent insertions can be hindered by stent-stent interference, making it difficult to achieve and position adequate drainage in strictures involving three or more intrahepatic ducts.\"},{\"question\":\"What stent technology was used to facilitate drainage of multiple ducts?\",\"answer\":\"A multi-hole self-expandable metallic stent (MHSEMS) with a thin 5.9-Fr delivery system and side-hole design was used to support drainage of multiple ducts while preserving communication between biliary branches.\"},{\"question\":\"How was the procedure performed in the reported case?\",\"answer\":\"After emergency ERCP with two temporary 5-Fr double-pigtail plastic stents, reintervention used a duodenoscope with a 4.5-mm working channel. Cholangiography confirmed three dilated hepatic ducts, and three MHSEMSs were inserted simultaneously and deployed under fluoroscopic guidance, achieving effective drainage.\"}]","DEN Open - Case Report - Simultaneous Placement of Three Thin-Delivery Multi-Hole Self-Expandable Metallic Stents for Malignant Hilar Biliary Obstruction | PDF",1790708702,13]