A novel controllable catheter with a short flexible tip for guidewire insertion in severe malignant hilar biliary stricture

During stenting for a malignant hilar biliary obstruction (MHBO), guidewire insertion to the intended intrahepatic bile duct is sometimes very technically challenging [1]. It is especially difficult when the bend in the bile duct is steep and involved in the stricture. A novel controllable catheter (Zeon Medical, Tokyo, Japan) with a short flexible tip is more flexible and can be bent more than conventional controllable catheters (Swing Tip cannula; Olympus Medical Systems, Tokyo, Japan) [2], which have a range of 90 degrees upwards and downwards. Furthermore, the fulcrum for the tip bend is closer to the tip (15mm) than in the conventional catheter (30mm) (▶Fig. 1). An 81-year-old man developed obstructive jaundice with cholangitis due to liver and lymph node metastases. Endoscopic retrograde cholangiography revealed a severe Bismuth type IIIa stricture, and the bifurcation angle of the left hepatic duct (LHD) was extremely steep due to the displacement by metastatic lesions. The LHD was assumed to branch from near the upper end of the stricture. Although guidewire insertion into the LHD was attempted with various types of guidewires and a Swing Tip cannula, the procedure was unsuccessful. Therefore, we inserted the novel controllable catheter and bent its tip toward the LHD to adjust the axis. Subsequently, guidewire insertion into the LHD was achieved (▶Video 1). Thereafter, an additional guidewire was inserted into the right intrahepatic duct, and a bilateral metal stent placement using the stent-in-stent method was finally performed (▶Fig. 2). Clinical success with sufficient and effective drainage was obtained without any adverse events. E-Videos