Transpapillary Placement of a Multihole Covered Metal Stent Using a 5.9-Fr Delivery System Through a Forward-viewing Endoscope in Malignant Biliary Obstruction With Type I Duodenal Stenosis.

Concurrent malignant biliary obstruction (MBO) and type I duodenal stenosis represent a technically demanding scenario, as luminal narrowing frequently precludes passage of a standard side-viewing duodenoscope and limits conventional transpapillary drainage. Although endoscopic ultrasound-guided biliary drainage and percutaneous transhepatic biliary drainage are established alternative approaches, transpapillary drainage remains desirable when papillary access is achievable. We report a 66-year-old woman with stage IV pancreatic cancer who presented with obstructive jaundice and tumor-related type I duodenal stenosis (i.e., obstruction proximal to the papilla). A side-viewing duodenoscope failed to traverse the stenosis; however, a standard forward-viewing endoscope (GIF-Q260J) successfully reached the major papilla. Selective biliary cannulation was achieved, and a covered multihole self-expandable metal stent (SEMS) (HANAROSTENT Biliary Multihole Benefit) was deployed across the distal biliary stricture using an ultra-slim 5.9-Fr delivery system compatible with the 3.2-mm working channel. Stent placement was technically successful without adverse events, resulting in prompt resolution of cholangitis and enabling the initiation of second-line chemotherapy. This case highlights a practical and reproducible strategy that expands the therapeutic capability of standard forward-viewing endoscopes. The combination of a slim delivery system and covered multihole SEMS may provide a physiological alternative to non-transpapillary drainage in selected patients with MBO and advanced type I duodenal stenosis.