This is a 59 years old patient who was recently diagnosed with pancreatic adenocarcinoma metastatic to the liver. MRCP showed bilateral intrahepatic biliary dilation with abrupt central termination (these findings were compatible with Bismuth IV tumor). He underwent PTCA with right liver external-internal drain placement, and ERCP with left liver plastic stenting. He presented to us with rising LFTs due to accidental displacement of stents. The right percutaneous drain was replaced by the IR team. The scout film demonstrates a completely upmigrated plastic biliary stent. Our plan was to stent multiple liver segments with 8mm tight-meshed metal stents deployed side-by-side. The upmigrated biliary stent was first removed by a stent grabber. The obstructed liver segments were then accessed separately by passing guidewires into left segment 2/3, left segment 4, and right anterior sectoral duct. The right liver percutaneous drain was removed by the IR team. The left segment 2/3 was stented first since it is most angulated. The catheter was advanced over the guidewire, and three stents were deployed inside each other. The catheter was then advanced over the guidewire into left segment 4, and two stents were deployed inside each other. The catheter was finally advanced over the guidewire into right anterior sectoral duct, and two stents were deployed inside each other. The distal end of each stent system was crossing ampulla. There was a marked improvement in LFTs, and patient was started on chemotherapy. We have found this technique of deploying tight-meshed metal stents side-by-side not only to work better than open-meshed stents deployed in Y-configuration, but easier to access each liver segment separately if stents occlude on that side.
Shahzad Iqbal, MD, Columbia University Medical Center
Peter D. Stevens, MD, Columbia University Medical Center