Case Report
A 61-year-old woman underwent orthotopic liver transplant, with intraoperative plastic biliary stent placement, for nonalcoholic steatohepatitis–related cirrhosis. When she presented a month later for the stent removal, the stent was noted to have migrated proximally into the donor bile duct on x-ray and computed tomography imaging (Figure 1). Endoscopic retrograde cholangiopancreatography with multiple extraction techniques failed to retrieve the stent. A single-operator digital cholangioscope (SpyGlass, Boston Scientific, Marlborough, Massachusetts) was used to identify the stent in the donor bile duct (Figure 2), which was then successfully extracted with the help of mini biopsy forceps (SpyBite, Boston Scientific, Marlborough, Massachusetts; Figure 3 and Video 1).
Figure 1.
(A) Abdominal x-ray revealing biliary stent in situ with no free air noted. (B) Computed tomography showing proximal migration of biliary stent into donor bile duct with no upstream ductal dilation.
Figure 2.
Cholangiogram revealed tortuosity of the bile duct.
Figure 3.
Intact extracted biliary stent.
Video 1.
Removal of proximally migrated biliary stent.
Liver transplantation can be life-saving for patients with a variety of conditions, including but not limited to cirrhosis and hepatocellular carcinoma. Intraoperative biliary stent placement decreases the risk of anastomotic biliary strictures.1 These stents are usually taken out within a month after the transplant. Stent migration occurs in 5% of cases, with distal migration more commonly reported.2 Proximal migration into the donor biliary duct is relatively rare.
In this case, we demonstrate that a cholangioscope can be successfully used for difficult cases of proximally migrated biliary stents in transplant patients. The SpyBite forceps that was used to retrieve the stent is 270 cm long with an outer diameter of 1 mm, designed to easily fit the working channel of the cholangioscope. This also allows for a 4.1-mm jaw opening at 55° for tissue acquisition. The use of cholangioscopy to retrieve a foreign body is not novel, and it has been used previously to remove challenging impacted/migrated foreign bodies in the pancreaticobiliary system.3-5 This case describes the retrieval of a migrated surgical biliary stent using a cholangioscope and mini biopsy forceps.
Disclosures
Author contributions: All authors contributed equally to the manuscript. S. Raghavapuram is the article guarantor.
Financial disclosures: None to report.
Informed consent was obtained for this case report.
References
- 1.Kusano T, Randall HB, Roberts JP, Ascher NL. The use of stents for duct-to-duct anastomoses of biliary reconstructions in orthotopic liver transplantation. Hepatogastroenterology. 2005;52(63):695–9. [PubMed] [Google Scholar]
- 2.Minutolo V, Gagliano G, Buttafuoco A, Minutolo O, Mosca F, Puleo S. Biliary stent migration into the abdominal wall: A case report. Chir Ital. 2009;61(4):493–6. [PubMed] [Google Scholar]
- 3.Hasan M, Canipe A, Tharian B, Navaneethan U, Varadarajulu S, Hawes R. Digital cholangioscopy-directed removal of a surgical staple from a stricture bile duct. Gastrointest Endosc. 2015;82(5):958.. [DOI] [PubMed] [Google Scholar]
- 4.Girotra M, Raghavapuram S, Tharian B. Successful removal of deeply migrated pancreatic stent using biliary dilation balloon and the new single-operator digital cholangioscope. Gastrointest Endosc. 2016;84(6):1061.. [DOI] [PubMed] [Google Scholar]
- 5.Tsuchiya T, Itoi T, Sofuni A, Tsuji S, Ikeuchi N. Rescue of basket-impacted stone by use of electrohydraulic lithotripsy under cholangioscopy. Gastrointest Endosc. 2014;79(3):376.. [DOI] [PubMed] [Google Scholar]