# Simultaneous Placement of Three Thin‐Delivery Multi‐Hole Self‐Expandable Metallic Stents for Malignant Hilar Biliary Obstruction Using a Large‐Channel Duodenoscope

## TL;DR

A new method using three thin stents placed simultaneously via a large-channel duodenoscope is described for treating complex bile duct blockages.

## Contribution

A novel approach using three thin multi-hole self-expandable metallic stents is introduced for malignant hilar biliary obstruction.

## Key findings

- Three MHSEMSs were successfully placed simultaneously through a large-channel duodenoscope.
- The stents expanded adequately, achieving effective drainage in a patient with Bismuth IV hilar obstruction.
- This method overcomes technical limitations of stent interference seen with traditional plastic stents.

## Abstract

Endoscopic biliary drainage for malignant hilar biliary obstruction is technically demanding especially when multiple ducts require drainage. Plastic inside stents are widely used because of their removability and ease of exchange, but multiple insertion is often hindered by stent interference. Recently, a multi‐hole self‐expandable metallic stent (MHSEMS) with a thin 5.9‐Fr delivery system and side‐hole design has been developed to facilitate multi‐duct drainage while maintaining communication between biliary branches. An 86‐year‐old woman presented with fever and vomiting. Laboratory data showed severe inflammation and mild cholestasis. Non‐contrast computed tomography and magnetic resonance cholangiopancreatography revealed Bismuth IV hilar obstruction. Emergency endoscopic retrograde cholangiopancreatography achieved drainage by placing two 5‐Fr double‐pigtail plastic stents into the right anterior and left ducts. After improvement, reintervention was performed using a new duodenoscope (ED‐840T; FUJIFILM, Tokyo, Japan) with a 4.5‐mm working channel. Cholangiography confirmed dilatation of three hepatic ducts. Three MHSEMSs were inserted simultaneously through their thin 5.9‐Fr delivery systems and deployed under fluoroscopic guidance. All stents expanded adequately, achieving effective drainage. This approach may represent an alternative to multi‐inside‐stent placement, overcoming the technical limitations of stent interference.