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usually unresectable at the time of diag− nosis and requires multiple biliary stent− ings. Metallic mesh stents remain patent for a relatively long time in the biliary stricture compared to tube stents [1]. However, employing multiple metallic mesh stents is sometimes very difficult because of their small lumen, which im− pedes the delivery of a catheter. The Soe− hendra stent retriever (Soehendra SR; Wilson−Cook Medical Inc., Winston− Salem, North Carolina, USA) is useful for dilating a stenosed biliary or pancreatic duct [2 ±4]. We used it to expand the mesh holes in metallic mesh stents placed in patients with malignant biliary hilar stricture who were undergoing mul− tiple stenting. We used the retriever in three patients with unresectable hilar biliary carcinoma. l" Fig. 1a shows the endoscopic cholan− giogram of a patient with a Bismuth type III stricture. A guide wire was negotiated into the right biliary tree and a metallic mesh stent inserted (JoStent SelfX stent; Abbott Vascular Devices, Redwood City, California, USA) (l" Fig. 1b). Then, a sec− ond guide wire was negotiated into the left biliary tree through a mesh hole in the first stent. Despite several attempts using dilation catheters, it was not possi− ble to insert them into the left biliary tree because of the small mesh holes of the stents. We therefore introduced a Soe− hendra SR and advanced it along the guide wire, turning it clockwise to allow the threads at the end of the device to en− gage the mesh and expand the stent hole (l" Fig. 2 a). After expansion, a metallic mesh stent delivery catheter was easily introduced into the biliary tree (l" Fig. 2 b) and multiple stenting was achieved (l" Fig. 2 c). We successfully car− ried out multiple stenting using metallic mesh stents in two other patients and no relevant complications were encoun− tered. Our results indicate that the Soe− hendra SR was useful in expanding the mesh holes of a metallic stent in patients requiring multiple stenting with metallic mesh stents.

Expansion of metallic mesh stent hole using a Soehendra stent retriever in multiple stenting of biliary hilar obstruction