LAUSR

The simultaneous triple stent-by-stent (SBS) technique can prevent failure of the third stent insertion for trisectoral metal stenting in patients with malignant hilar biliary obstruction (MHBO) [1, 2] However, simultaneous insertion of three stent delivery systems is often challenging, especially for tight strictures. Endobiliary radiofrequency ablation (RFA), which can prolong stent patency in MHBO [3], renders the stricture and tumor degenerative [4], resulting in decreased tightness of the stricture. Here, we describe an initial case of simultaneous triple SBS deployment following endobiliary RFA for unresectable MHBO. A 78-year-old man developed obstructive jaundice because of Bismuth type IIIa MHBO. As diameter of the common bile duct was large, we chose the triple SBS method. After placement of three guidewires into the left hepatic duct (LHD), anterior branch of the right hepatic duct (a-RHD), and posterior branch of the RHD (p-RHD), the RFA catheter (Habib EndoHPB catheter; Boston Scientific, Marlborough, Massachusetts, USA) was introduced over the LHD guidewire, and the stricture of the LHDwas subsequently ablated for 90 seconds at 7W (VIO300D generator; ERBE Elektromedizin GmbH, Tübingen, Germany). Then, the stricture of the RHD was also ablated over the p-RHD guidewire using the same settings. After RFA, three metal stents (Zeo Stent V; Zeon Medical, Tokyo, Japan) were simultaneously introduced and passed smoothly through the stricture. Finally, the stents were released and placed in the order LHD, p-RHD, a-RHD (▶Fig. 1, ▶Video 1). All stents used were 8mm in diameter and 80mm in length. Video 1 Simultaneous triple stent-by-stent deployment following endobiliary radiofrequency ablation in a patient with high-grade malignant hilar biliary obstruction. ▶ Fig. 1 Triple stent-by-stent deployment. a, b After three guidewires were inserted across the Bismuth type IIIa stricture, radiofrequency ablation was performed to the left and right hepatic duct strictures. c Three metal stent delivery systems were simultaneously introduced to the left, right posterior, and right anterior hepatic ducts. d The stents were released and placed in a stent-by-stent manner with their distal ends at the same level. E-Videos