Successful endoscopic removal of a retained guidewire in the intrahepatic bile duct using a novel tapered sheath dilator

A 58-year-old man with a history of lung transplantation underwent ERCP to assess the cause of solitary biliary stricture in the right posterior branch (B7) (Fig. 1), but the guidewire passage across the stricture was unsuccessful at the initial session despite the use of bendable cannula and double lumen cannula along with a hydrophilic guidewire. Percutaneous transhepatic biliary drainage (PTBD) was then attempted as a salvage procedure, but the guidewire was retained due to the shearing at the needle tip (Fig. 2). In the subsequent ERCP, access to B7 was successful using the retained guidewire as a landmark (Fig. 3), but the retrieval of the guidewire was unsuccessful even after multiple attempts using a basket catheter and cholangioscope due to the limited working space. Therefore, a novel tapered sheath dilator (EndoSheather; Piolax Medical Devices, Kanagawa, Japan), which allows insertion of a device up to 1.9 mm in diameter (Fig. 4), was inserted into B7 across the stricture, and pediatric biopsy forceps (Radial Jaw 4P Biopsy Forceps; Boston Scientific Japan, Tokyo, Japan) were advanced through the outer sheath after removing the inner catheter (Fig. 5). We successfully grasped and retrieved the retained guidewire using the biopsy forceps under fluoroscopic guidance without any adverse events (Fig. 6; Video 1, available online at www.videogie.org). Biopsy of the stricture located at B7 was negative for cancer.

Figure 1.

CT and MRCP revealed localized biliary dilatation at B7.

Figure 2.

Percutaneous transhepatic biliary drainage was attempted; the guidewire was retained due to the shearing at the needle tip.

Figure 3.

Access to B7 was successful using the retained guidewire as a landmark.

Figure 4.

A novel tapered sheath dilator.

Figure 5.

Biopsy forceps through the outer sheath of the novel tapered sheath dilator after removing the inner catheter.

Figure 6.

The retained guidewire was removed successfully using a novel tapered sheath dilator and biopsy forceps.

Retained guidewire is not a rare adverse event during endoscopic and percutaneous interventions for pancreatobiliary diseases.^1,2 This can occur due to excessive force or torque applied to the guidewire, or interference between the guidewire and devices such as a needle and catheter. Previous reports have suggested that gentle traction and limited torquing (fewer than 30 rotations) might prevent the shearing of guidewire.³ It is essential to remove a retained guidewire, as it poses risks of biliary or pancreatic infection.^4,5 The current report documents successful endoscopic removal of a retained guidewire above the stricture using a novel tapered sheath dilator. In contrast to the conventional biliary dilator, this novel device allows both stricture dilation and delivery of devices up to 1.9 mm across the stricture, such as pediatric biopsy forceps,⁶ and can be useful for foreign body retrieval above the stricture.⁷

Case

A 58-year-old man with a history of lung transplantation was diagnosed with solitary biliary stricture in the right posterior branch (B7) based on CT and magnetic resonance imaging.

The patient underwent ERCP to assess the cause of the biliary stricture at B7, but the guidewire passage was unsuccessful.

PTBD was then attempted as a salvage procedure, but the guidewire could not pass through the stricture and was retained due to the shearing at the needle tip. We exchanged to another guidewire but were unable to pass through the stricture.

We attempted ERCP again. We successfully accessed B7 using the retained guidewire as a landmark. We exchanged from a hydrophilic guidewire to the 0.025-inch hard wire and dilated the stricture using a balloon dilation catheter. However, we failed to retrieve it even after multiple attempts. After first attempting to use a basket catheter, the limited working space and difficulty in grasping the retained guidewire caused failure.

Next, we performed cholangioscopy, but the choledochoscope was unable to pass thorough the tight angle of poste root portion and did not reach the stricture at B7.

A novel tapered sheath dilator was inserted into B7 over the wire, as it has a good trackability. After removing the inner catheter and placed guidewire, biopsy forceps were advanced through the outer sheath.

We successfully grasped and retrieved the retained guidewire using novel tapered sheath dilator and biopsy forceps under fluoroscopic guidance without any adverse events.

In conclusion, we successfully removed the retained guidewire above the biliary stricture using a novel tapered sheath dilator and biopsy forceps. This novel tapered sheath dilator can be useful for foreign body retrieval above the stricture. Biopsy of the stricture located at B7 was negative for cancer. The novel tapered sheath dilator can be inserted over the wire for long guidewire. The inner sheath of this device features a tapered shape and facilitating passage through stricture. This novel device enables the delivery of devices up to 1.9 mm across the stricture through the outer sheath after removing the inner sheath and guidewire.

Disclosures

Dr Nakai received research grant and honoraria from Boston Scientific Japan. All other authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Successful endoscopic removal of a retained guidewire in the intrahepatic bile duct using a novel tapered sheath dilator.