LAUSR

An 86-year-old man who had undergone placement of multiple uncovered self-expandable metal stents (U-SEMSs) by the stent-in-stent (SIS) method for hilar cholangiocarcinoma presented with fever. Blood tests revealed elevated levels of inflammatory markers and liver enzymes. Computed tomography showed intrahepatic bile duct dilatation due to U-SEMS obstruction caused by tumor ingrowth, and peripheral early enhancement probably due to cholangitis (▶Fig. 1). Endoscopic retrograde cholangiography was performed for additional stent placement. After guidewires had been placed in the left and right intrahepatic ducts through the U-SEMSmeshes, it was possible to pass a balloon dilation catheter (REN 6mm; KANEKA, Osaka, Japan) through and dilate the meshes. However, a cannula (MTW; Endoskopie, Wesel, Germany) could not be passed through the meshes. We used a novel delivery device (EndoSheather; Piolax, Kanagawa, Japan) that could be passed through along the guidewires and dilate the meshes. Following the removal of the inner catheter, a 5-Fr endoscopic nasobiliary drainage (ENBD) tube (Silky Pass; Boston Scientific, Tokyo, Japan) was placed in the left intrahepatic duct through the outer sheath (▶Fig. 2; ▶Video 1), and another ENBD tube was placed in the right intrahepatic duct. Re-intervention for obstruction of U-SEMSs placed by the SIS method can be technically challenging [1, 2]. Recently, we developed a novel delivery device composed of an inner catheter with a tapered tip and an outer sheath with no caliber difference. With this device, various devices up to 6 Fr can be delivered into the bile duct through the outer sheath, which has an inner diameter of 6.5 Fr [3, 4]. In this case, not only did the tapered shape and moderate stiffness of this novel device aid its passage through the U-SEMS meshes, but the outer sheath also served as a conduit for easy placement of an ENBD tube (▶Fig. 3). This novel delivery device may be useful for additional stenting through the meshes of U-SEMSs placed by the SIS method.