Side-by-side 6-mm multi-hole metal stents more effective than inside plastic stents for reintervention after stent-in-stent placement in malignant hilar biliary obstruction

Sep 30, 2026

Uploaded by dabgoudw

Online case report describing endoscopic reintervention for malignant hilar biliary obstruction after stent-in-stent placement. It addresses the challenge that additional uncovered self-expandable metallic stents can limit future endoscopic options, while plastic stents require revision because of shorter patency and need for repeat interventions. An 84-year-old patient with recurrent stent occlusion underwent guidewire placement, removal of existing plastic stents, and side-by-side insertion of two 6-mm multi-hole slim delivery metallic stents with favorable outcome and no adverse events.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Case report overview

Background and clinical challenge

Procedure and outcome

Advantages of 6-mm multi-hole metal stents

Article published online: 2026-01-08 Side-by-side 6-mm multi-hole metal stents more effective than inside plastic stents for reintervention after stent-in-stent placement in malignant hilar biliary obstruction ▶Fig. 1 Pre-treatment images. a A fluoroscopic image showing plastic stents placed after stent-in-stent deployment of metallic stents for malignant hilar biliary obstruction. b A pre-treatment computed tomography image showing dilated intrahepatic bile ducts. Endoscopic reintervention after the stent-in-stent (SIS) placement of self-expandable metallic stents (SEMSs) for unresectable malignant hilar biliary obstruction (MHBO) is challenging [1] . Regarding revisionary stenting, SEMSs have a longer patency than plastic stents (PSs [2]), but advances in chemotherapy have increased the need for reinterventions, often using removable PSs. Additional uncovered SEMSs (UCSEMSs) can complicate future reinterventions and cannot be removed, limiting endoscopic options. We report a case of MHBO in which the side-by-side placement of the 6mm multi-hole SEMS (MHSEMS) was effective for reintervention compared with multiple PSs after SIS. An 84-year-old woman with MHBO, previously treated with the MHSEMS and UCSEMS in SIS placement followed by two PSs, was admitted with cholangitis ( ▶ Fig.1) . She had experienced repeated stent occlusion over a short period, so we opted to place two removable SEMSs ( ▶Video 1) . A guidewire (GW) was placed into the left intrahepatic bile duct (IHBD), and both PSs were removed. Another GW was placed into the right IHBD, and two 6mm MHSEMSs with a slim delivery system were inserted. Insertion into the deep left IHBD was somewhat difficult, so the stents were inserted one by one but deployed simultaneously across the papilla ( ▶ Fig.2) . No adverse events occurred, and the outcome was favorable. The advantages of the MHSEMS have no step between the delivery system and the stent and it has an outer diameter of 5.9Fr. In this case, placement of a 7Fr PS was difficult and time-consuming due to interference from the existing SEMS; however, the MHSEMS could be placed ina much shorter time. Furthermore, after deployment, the inner diameter is larger than that of a PS, and the two MHSEMSs share each other ’s holes, providing a drainage effect equivalent to more than 6mm. The MHSEMS is also removable [3], making it a favorable option for reintervention. Endoscopy_UCTN_Code_TTT_ 1AR_ 2AZ Contributors ʼ Statement Hirotsugu Maruyama: Conceptualization, Writing – original draft. Kojiro Tanoue: Writing – review & editing. Yuji Kawata: Writing – review & editing. Tatsuya Kurokawa: Writing – review & editing. Yoshinori Shimamoto: Writing – review & editing. Yuki Ishikawa-Kakiya: Writing – review & editing. Yasuhiro Fujiwara: Writing – review & editing. Conflict of Interest The authors declare that they have no conflict of interest. Maruyama Hirotsugu et al. Side-by-side 6-mm multi-hole… Endoscopy 2026; 58: E11–E12 | © 2026. The Author(s) . E11 ▶Fig.2 Procedure for reintervention using the side-by-side placement of multi-hole selfexpandable metallic stents (MHSEMSs) . a An endoscopic image showing two plastic stents placed 1 month ago. bAn endoscopic image showing simultaneous insertion of two MHSEMSs with a slim delivery system into the bile duct. c Two MHSEMSs were deployed simultaneously. d and e Endoscopic and fluoroscopic images after MHSEMS deployment. The authors Hirotsugu Maruyama1 , Kojiro Tanoue1 , Yuji Kawata1, Tatsuya Kurokawa1, Yoshinori Shimamoto1, Yuki Ishikawa-Kakiya1, Yasuhiro Fujiwara1 1 Department of Gastroenterology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan Corresponding author Hirotsugu Maruyama, MD, PhD Department of Gastroenterology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan [hiromaruyama99@gmail.com](hiromaruyama99@gmail.com) References [1] Guilmoteau T

FAQs

Why is endoscopic reintervention difficult after stent-in-stent placement for malignant hilar biliary obstruction?

Additional uncovered self-expandable metallic stents used in stent-in-stent strategies can complicate future reinterventions and are not removable, limiting available endoscopic options.

What approach was used for reintervention in the reported case?

Existing plastic stents were removed after guidewire placement into left and right intrahepatic bile ducts, followed by simultaneous insertion of two 6-mm multi-hole slim delivery metallic stents across the papilla.

What advantages were reported for the 6-mm multi-hole metal stents compared with plastic stents?

The multi-hole metal stent has a delivery system with no step, a smaller outer diameter, can be deployed in less time despite interference from existing stents, provides a drainage effect larger than a comparable plastic stent, and is removable.

Sep 30, 2026

Uploaded by dabgoudw