A torque-driven drill dilator to enable Y-configuration biliary stent placement for high-grade hilar obstruction

Background and Aims: Endoscopic management of malignant hilar biliary obstruction is technically challenging, particularly with high-grade strictures.Dual-sector metal stent placement using a stent-in-stent (Y) configuration may be preferred to allow durable, suprapapillary, re-accessible drainage.However, traversing the mesh of the first stent into the second sector with dilating catheters can be challenging.A newly available spiral drill dilator (Tornus ES; Asahi Intecc Co, Aichi, Japan) can be used in such cases.Methods: A 74-year-old woman with Bismuth type IIIa cholangiocarcinoma presented with biliary obstruction and underwent endoscopic retrograde cholangiopancreatography for dual-sector, uncovered metal stent placement in a Y configuration.After a left-sector uncovered metal stent was placed, the right anterior hepatic duct was accessed but could not pass the balloon catheter.A drill dilator was then advanced with clockwise rotation. Results:The drill dilator enabled successful stricture passage and creation of a tract through the mesh of the first stent, permitting placement of a second uncovered metal stent in a Y configuration. Conclusions:This case demonstrates the utility of a newly available spiral drill dilator for enlarging the pathway through the mesh of a single metal stent to place a second metal stent for Y-configuration dual-sector biliary drainage.