A 72-year-old woman was admitted to the hospital complaining of right upper quadrant pain. Initial abdominopelvic CT showed hepatic hilar obstruction due to cholangiocarcinoma, extending from hilum of extrahepatic bile duct to distal common bile duct. Elevated total bilirubin level (13.0 mg/dL) and direct bilirubin level (10.8 mg/dL) were found at admission. Alkaline phosphatase level (1189 IU/L) and gamma-glutamyl transpeptidase (229 mg/dL) were also elevated. Percutaneous transhepatic biliary drainage (PTBD) through the right intrahepatic bile duct (Fig. 1B-a) resulted from a Bismuth type II cholangiocarcinoma. We planned on the newly designed Y-shaped covered stent insertion on the fourth day after the initial drainage procedure, and performed another PTBD through the left intrahepatic bile duct (S3 duct) (Fig. 1B-b).
Before inserting the Y-shaped biliary covered stent, the drainage catheters were removed and 8 Fr sheaths inserted over a 0.035-inch hydrophilic guide wire (Terumo, Tokyo, Japan) bilaterally. First, we inserted and located the main piece of stent into the common bile duct through left PTBD tract (Fig. 1C). The proximal end of the main piece stent (EGIS KEY-MB stent) (S&G Bio, Seoul, Korea) was located in the left intrahepatic bile duct (IHD) beyond the boundary of the hilar tumor (Fig. 1C, thick arrows). The short limb covered portion of the main piece stent was directed toward the left side of the common bile duct (Fig. 1C, thin arrows). To easily insert and deploy the contra-lateral long limb covered stent (EGIS KEY-CL stent) (S&G Bio, Seoul, Korea) without kinking its struts, the long limb covered stent of the main piece was not to be deployed (Fig. 1D, three thick arrows) until the contra-lateral long limb covered stent was completely deployed in an adequate position. After successful negotiation of a guide wire into the short limb covered stent of the main piece, a contra-lateral long limb covered stent was inserted through the right PTBD tract to connect this short limb covered stent of the main piece under the guidance of a 0.035-inch guide wire. After the confirmation that its proximal end was located in the right IHD beyond the boundary of the hilar tumor, we deployed the contra-lateral long limb covered (Fig. 1E). Finally, the long limb covered stent of the main piece was completely deployed. A 7 Fr drainage catheter was placed through the left IHD with its tip located in the common bile duct. To confirm the correct stent expansion and function, post-stenting cholangiography was performed through the drainage catheter just after the stent insertion (Fig. 1F) and 7 days later. Cholangiography showed good bilateral communication via completely expanded stents, and the drainage catheter was removed. On eighth day following the stent placement, total bilirubin and direct bilirubin levels decreased to 2.7 mg/dL and 2.2 mg/dL, respectively. They have not been elevated in the 12 months following the Y-shaped covered stent insertion (total bilirubin/direct bilirubin = 0.9/0.5 mg/dL).