Fig. 3. A 71-year-old male with biliary cancer after pancreaticoduodenectomy with modified Child reconstruction underwent endoscopic metallic stent placement for distal-site obstruction previously (Patient 4). (A) Computed tomography showed the dilation of afferent loop (arrows) and the metallic stent placed endoscopically (arrow head). (B, C) Percutaneous drainage via the blind end of the jejunal limb (arrows) was performed under ultrasound guidance, and 8-F drainage catheter was inserted into the afferent loop. (D) Contrast study via the seeking catheter passed through the obstructed portion showed the short distance between the hepaticojejunostomy (black arrow) and the obstructed portion (white arrows). (E) A metallic stent delivery system could be passed through the obstructed portion along with a super-stiff guide-wire. (F) One bare metallic stent (Zilver Biliary Stent, 10 mm diameter, 80 mm long) was placed across the hepaticojejunostomy (black arrows). Subsequently, another covered metallic stent (Niti-S Biliary Stent, 10 mm diameter, 80 mm long) was placed across the obstructed portion using stent-in-stent technique (white arrows).
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