Multi-hole two-way hybrid placement using three 8-mm metal stents for malignant hilar biliary obstruction

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Abstract
Multidisciplinary treatment for malignant hilar biliary obstruction (MHBO) has improved, and biliary drainage has become increasingly important. Liver drainage of more than 80% is associated with prolonged survival [1]; however, the placement of three or more metal stents is technically challenging and therefore not commonly performed. Nevertheless, such extensive stenting may be required in cases of cholangitis or insufficient biliary drainage. Uncovered self-expandable metal stents (SEMSs) are generally used; however, they cannot be removed, and sequential stent insertion through the mesh becomes difficult. Herein, we report a case of MHBO with insufficient biliary drainage in which adequate drainage was successfully achieved by hybrid placement using three multi-hole self-expandable metal stents (MHSEMSs). A 72-year-old woman with hilar cholangiocarcinoma accompanied by peritoneal dissemination was undergoing chemotherapy. Plastic stents (PSs) had been placed in the right and left bile ducts ([Fig. 1]); however, liver enzyme levels remained elevated. To allow the stable continuation of chemotherapy, the PSs were exchanged for SEMSs. Cholangiography revealed bismuth type IV, with multiple strictures observed in the right anterior hepatic duct. To achieve more effective biliary drainage, the placement of three SEMSs was planned. First, three guidewires (GWs) were advanced into the target bile ducts, and the MHSEMSs were simultaneously deployed in the right and left bile ducts using a side-by-side placement. Subsequently, a GW was advanced into the right anterior hepatic duct through a hole in the right MHSEMS, and a third MHSEMS was deployed using a stent-in-stent placement ([Fig. 2]; [Video 1]). The procedure was completed without adverse events, and liver enzyme levels normalized. This method is expected to provide a longer patency period and a lower risk of tumor ingrowth [2]. Most importantly, because only a single passage through the stent mesh is required, this technique facilitates for trisegment drainage ([Fig. 3]) and is removable [3] [4]. Endoscopy_UCTN_Code_TTT_1AR_2AZ Article published online: 20 April 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany