Background and study aims Stent migration into the abdominal cavity, which can occur due to stent shortening or stomach mobility, is a critical adverse event (AE) in EUS-HGS. To prevent this AE due to stent shortening, a novel, partially covered self-expandable metal stent with an antimigratory single flange has recently become available in Japan. The present study evaluated the clinical feasibility and safety of EUS-HGS using this novel stent. Patients and methods We measured stent length in the abdominal cavity and the luminal portion after EUS-HGS using computed tomography (CT) performed 1 day after EUS-HGS (early phase). To evaluate stent shortening and the influence of stomach mobility, we also measured stent length at the same sites on CT performed at least 7 days after EUS-HGS (late phase). Results Thirty-one patients successfully underwent EUS-HGS using this stent. According to CT in the early phase, stent length in the abdominal cavity was 7.13 ± 2.11 mm and the length of the luminal portion was 53.3 ± 6.27 mm. Conversely, according to CT in the late phase, stent length in the abdominal cavity was 8.55 ± 2.36 mm and the length of the luminal portion was 50.0 ± 8.36 mm. Stent shortening in the luminal portion was significantly greater in the late phase than in the early phase (P = 0.04). Conclusions CT showed that stent migration can occur even with successful stent deployment, due to various factors such as stent shortening. The antimigratory single flange may be helpful to prevent stent migration, but further prospective comparative studies are needed to confirm our results.

Background: After multiple uncovered self-expandable metal stent (UCSEMS) deployments, endoscopic revision becomes complex and potentially challenging. A novel stent delivery system with a dilation function has recently been developed in Japan. This study evaluated the technical feasibility of this device for patients with unresectable malignant hilar biliary obstruction (MHO) after multiple UCSEMS deployments. Method: Participants comprised consecutive patients with unresectable MHO who had undergone multiple UCSEMS deployments and required endoscopic revision for the right or left hepatic bile ducts, as decided by cholangiography under endoscopic retrograde cholangiopancreatography (ERCP) guidance. Results: A total of 14 patients requiring endoscopic revision of right and left hepatic bile ducts were enrolled in this study. Among these 14 patients, guidewire insertion through the mesh of previously placed stents failed in 2 patients. As a result, these two patients underwent only unilateral UCSEMS deployment. Because clinical success was not obtained, transmural placement of the UCSEMS under Endoscopic Ultrasound (EUS) guidance to the segment of the liver not being drained was performed in those patients. The molting technique was attempted in 12 patients, proving successful in all patients. The technical success rate was therefore 92.8% (12/14). Mean procedure time was 23.2 min. Conclusion: This novel stent delivery system with a dilation function may be useful in endoscopic revision techniques for bilateral UCSEMS deployment.

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Pancreatic duct stenting is a feasible technique for the treatment of symptomatic pancreatic duct obstruction. However, pancreatic obstruction because of impaction of large pancreatic duct stones makes the insertion of various devices, including plastic stents, challenging. Recently, a novel stent delivery system with a dilation function (EndoSheather; Piolax Medical Devices, Kanagawa, Japan) has become available in Japan. The diameter of the outer sheath of this device is 7.2Fr, and that of the inner sheath is 5.9Fr. In addition, the tip of this device is extremely tapered (3.9Fr), conforming to a 0.035-inch guidewire. These characteristics allow for easier penetration of the stricture site, and after removal of the inner sheath, various devices less than 5.9Fr in size can be inserted. A recently available small-caliber plastic stent (5Fr, Through & Pass Type IT; Gadelius Medical, Tokyo, Japan) can also be inserted within this outer sheath. We herein describe technical tips for a novel pancreatic duct stent technique using the EndoSheather, which is called the "Molting technique" (a). A 49-year-old man was admitted to our hospital to be treated for frequent pancreatitis because of impaction of a large pancreatic duct stone, for which endoscopic retrograde cholangiopancreatography was attempted. Although a 0.025-inch guidewire was successfully advanced into the main pancreatic duct across the pancreatic stone, several devices, including a Soehendra stent retriever, could not be inserted. Therefore, EndoSheather insertion was attempted. Although this device was successfully inserted, the tip of the device barely passed through the site of obstruction. Subsequently, the inner sheath of the EndoSheather was removed, and a small-caliber plastic stent was inserted into the outer sheath. Finally, we removed the outer sheath and retained the plastic stent (b). He discharged without any adverse events and also underwent contentious stent exchange. The presented technique might be useful for pancreatic duct stenting in challenging cases. Watch the Video, Supplementary Digital Content 1, http://links.lww.com/AJG/C469.

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