Combined endoscopic stent-in-stent placement for malignant biliary and duodenal obstruction by using a new duodenal metal stent (with videos)

Background: Self-expandable metal stents (SEMSs) are an effective palliative treatment for malignant biliary or duodenal Strictures, but endoscopic stenting for combined malignant biliary and duodenal obstruction remains technically difficult. Objective: To evaluate the feasibility and clinical success rate of endoscopic double stent-in-stent placement by using a new duodenal metallic stent for the management of malignant biliary and duodenal obstructions. Design: Prospective, observational clinical feasibility study. Setting: Tertiary referral center. Main Outcome Measurement: Technical and clinical success, complications, midterm outcome. Patients and Methods: Eight patients with inoperable malignant biliary and duodenal strictures were enrolled. Endoscopic placement of a biliary SEMS was performed through the mesh of the duodenal stent. Results: The duodenal Strictures were in the first part of the duodenum in 3 patients (type 1.) and in the second part in 5 patients (type 2). Duodenal stents were successfully deployed in all patients. Endoscopic placement of a biliary, SEMS through the mesh of the duodenal stent was successful in 7 (87.5%) of 8 patients. In 2 of 3 patients with type 2 duodenal strictures with failed bile duct cannulation, biliary stenting was Successful by using the rendezvous procedure. Early complications occurred in 1 patient. The overall median Survival after combined stenting was 91 days (range 36-314 days). Limitations: Small number of patients and no comparison with other enteral stents. Conclusions: Biliary stenting through the new duodenal metallic stent is technically feasible and has a high success rate. Combined endoscopic biliary and duodenal stent-in-stent placement is a promising solution for the palliation of malignant biliary and duodenal obstruction.