Cystotome assisted stent recanalization : an alternative way of regaining access to occluded metal biliary stents

Increased survival of patients with malignant biliary strictures can present endoscopic challenges over time, as local tumor progression or in-stent granulation tissue may hamper biliary access (1,2). A 63-year-old male was referred to our endoscopy department following an episode of cholangitis (bilirubin level 2.2, upper limit of normal 1.0 mg/dl). One year earlier, diagnosis of a metastatic cholangiocarcinoma (Klatskin type IIIa) was made. Following triple stenting in Y-shaped configuration, with the upper two SEMS (Self Expandable Metal Stents) in juxtaposition, chemotherapy was initiated. Oncological reevaluation had recently shown disease regression, although in retrospect reduced patency of the left biliary stent could be suspected. ERCP was repeated, identifying a patent uncovered metal stent in the right biliary system. Despite multiple reintroductions, application of a rigid dilator and use of a balloon, the 0.025-inch guidewire could not be advanced into the left biliary system