Endoscopic balloon dissection to remove a percutaneously placed biliary stent with tissue ingrowth: a novel approach

Benign biliary strictures (BBSs) arise from various causes, with presentations ranging from mild cholestasis to recurrent cholangitis.^1,2 Endoscopic retrograde cholangiopancreatography (ERCP) with temporary placement of a fully covered self-expandable metal stent (FCSEMS) provides favorable outcomes.^3,4

Tissue ingrowth is an uncommon yet challenging adverse event of prolonged FCSEMS placement, making removal technically difficult.⁵ We present a novel technique for extracting an embedded FCSEMS.

A 65-year-old woman with a history of Roux-en-Y gastric bypass and BBS of unclear cause underwent percutaneous biliary drainage at outside hospital because of the lack of an experienced advanced endoscopist. Ultimately, a transpapillary 50 mm × 13 mm covered metallic stent (GORE Viabahn vascular stent; W.L. Gore & Associates, Flagstaff, Ariz, USA) was placed, although it was unclear why a vascular stent was used (Fig. 1).

Figure 1.

Fluoroscopic image of percutaneously placed vascular stent within common bile duct (arrows).

Four months after stent placement, the patient was referred to our facility for further management of BBS. After step 1 of gastric access temporary for endoscopy using a 20 × 10 mm lumen-apposing metal stent (Boston Scientific, Marlborough, Mass, USA), the patient returned for ERCP to have the biliary stent removed and tissue samples obtained. Removal was challenging because of tissue overgrowth around the stent's outer sheath and its large diameter. Attempts with a snare and graspers failed, and a stent-in-stent approach was not feasible given the 13-mm diameter of the vascular stent.

We used an endoscopic balloon dissection technique with an 8.5- to 15-mm biliary stone extraction balloon (Boston Scientific) and a 4-mm dilation balloon (Hurricane; Boston Scientific). A guidewire was advanced between the stent and the bile duct wall, followed by balloon inflation to separate the stent circumferentially (Fig. 2). After multiple inflations, the stent was removed by use of a snare without evidence of significant bleeding or ductal injury (Figs. 3, 4A, and 4B). The patient remained well at a 3-month follow-up visit.

Figure 2.

Fluoroscopic images. A, Guidewire and stone extraction balloon (arrows) passed adjacent to the stent into bile duct. B, Stone extraction balloon (white arrows) positioned adjacent to the proximal part of the stent (yellow arrows). C, Inflated balloon (white arrows) detaching the proximal part of the stent (yellow arrows) from bile duct.

Figure 3.

Vascular stent after removal.

Figure 4.

A, Endoscopic image of ampulla (arrow) after stent removal. B, Balloon occlusion cholangiogram showing no stricture or bile leak.

FCSEMSs effectively manage BBSs by maintaining ductal patency while minimizing tissue ingrowth. However, prolonged dwell time can lead to epithelial hyperplasia and embedment, complicating removal.⁵ Conventional removal methods include snares, forceps, biliary balloons, or a stent-in-stent strategy.⁵

This case demonstrates a novel balloon dissection technique for extracting embedded biliary stents when tissue overgrowth and/or large diameter hinder standard methods. Although the stent placed was a vascular stent, the technique still can be applied for conventional biliary FCSEMSs. Balloon dissection appears to be potentially safe and feasible with commercially available biliary balloons. To our knowledge, this technique has not been previously reported. Further studies are needed to assess this technique.

Patient Consent

Informed consent was obtained from the patient for the publication of their information and imaging.

Disclosure

The author disclosed no financial relationships.