LAUSR

IT HAS RECENTLY been reported that combined simultaneous stent-by-stent (SBS) and stent-in-stent (SIS) method (SBSIS) can reduce the technical difficulty of tri-sectoral metal stenting for high-grade malignant hilar biliary obstruction (MHBO). However, inserting a third metal stent (MS) remains challenging. More recently, simultaneous triple SBS placement using ultra-thin delivery systems has helped avoid failures of the third MS insertion, but this technique cannot be performed for non-largediameter common bile ducts. We therefore developed a “modified” SBSIS method to make insertion of the third MS more straightforward. A 76-year-old woman developed obstructive jaundice due to unresectable Bismuth type IIIa MHBO. As pre-drainage using two plastic stents was insufficient, tri-sectoral MS placement was performed. After insertion of three 0.025inch guidewires in the left hepatic duct (LHD), right anterior hepatic duct (aRHD), and right posterior hepatic duct (pRHD), two MSs (ZeoStent V; Zeon Medical, Tokyo, Japan) were simultaneously inserted into the LHD and pRHD. The pRHD MS was subsequently placed across the stricture. A tapered catheter was inserted over the pRHD guidewire, and the guidewire was re-manipulated into the aRHD through the stent mesh. Another MS was inserted into the aRHD and placed in the SIS fashion. Finally, the LHD MS was placed using SBS configuration, where the distal end was aligned with that of the pRHD stent (Fig. 1 and Video S1). Adequate drainage was obtained without procedure-related adverse events. The most difficult step of SBSIS is passing the distal stent end and the stent mesh after SBS placement. In modified SBSIS, which differs in the timing of the SIS procedure from the original SBSIS, these steps can be performed under the condition with one MS, which is the same as that in the conventional SIS method. Thus, modified SBSIS could further reduce difficulties of tri-sectoral metal stenting for MHBO. Authors declare no conflicts of interest for this article.