An 85-year-old man with no significant medical history presented to an outside hospital (OSH) with nausea, vomiting, and abdominal pain. His laboratory evaluation was concerning for biliary obstruction, and a CT of his abdomen and pelvis demonstrated a 10-mm stone in the distal common bile duct with upstream biliary dilation to 20 mm. An ERCP was performed at the OSH with biliary sphincterotomy, balloon sweep with removal of the stone, and placement of an 8.5F × 7-cm plastic stent in the common bile duct.
A repeat ERCP was performed 6 weeks later at the OSH for stent removal, at which point the stent was not visualized at the ampulla on endoscopic views. On cholangiogram, the stent had migrated proximally in the bile duct with the proximal end of the stent in the right hepatic duct (Fig. 1). Attempts at the OSH to remove the stent with balloon retrieval and forceps were unsuccessful, and the patient was transferred to a tertiary center for attempted removal (Video 1, available online at www.giejournal.org).1,2
Figure 1.
Initial cholangiogram from the outside hospital demonstrating proximal migration of the plastic biliary stent to the right hepatic duct.
Procedure
An ERCP was performed with a TJF 160VF duodenoscope (Olympus America, Chelmsford, Mass, USA), and on insertion the stent was not visualized at the ampulla. On cholangiogram, the right anterior hepatic duct contained a filling defect consistent with a migrated stent with the distal end of the stent in the mid extrahepatic bile duct (Fig. 2).
Figure 2.
Initial cholangiogram after transfer to tertiary referral center with attempted removal of proximally migrated biliary stent by balloon traction with a 15-mm stone extraction balloon.
Attempts to remove the stent with a 15-mm stone extraction balloon, rat-toothed forceps, 4-mm dilation balloon, Soehendra stent retriever (Cook Medical, Bloomington, Ind, USA), and lithotripsy basket were unsuccessful (Fig 3.) A SpyGlass Direct Visualization System (Boston Scientific, Marlborough, Mass, USA) was advanced to the right intrahepatic ducts, and a plastic stent was observed with the distal end of the stent impacted into the bile duct wall (Fig. 4).
Figure 3.
Attempts to remove the stent with rat-toothed forceps, 4-mm dilation balloon, Soehendra stent retriever, and lithotripsy basket (pictured here) were unsuccessful.
Figure 4.
The cholangioscope was inserted into the right anterior hepatic duct for direct visualization. The distal end of the biliary stent was impacted in the bile duct wall. The mini-snare was inserted through the cholangioscope to grasp the distal flange of the stent.
A mini-snare through the cholangioscope was used to grasp the distal flange of the plastic stent because the mini forceps were not thought to have enough grasp to overcome the impaction of the distal end of the stent in the bile duct wall (Fig. 5). Subsequently, the stent was pulled out of the bile duct, and the duodenoscope was removed while the stent remained ensnared.
Figure 5.
The stent was removed under direct and fluoroscopic visualization with the snare grasping the distal flange.
A follow-up cholangiogram was obtained, and there were no filling defects or evidence of a bile leak (Fig. 6). The cholangioscope was reinserted, and stent-related changes were observed in the right anterior hepatic duct (Fig. 7). A clean-based ulcer with heaped-up mucosal borders was observed at the site of stent impaction in the bile duct wall, which had not previously been appreciated on the cholangiogram (Fig. 8).
Figure 6.
Follow-up cholangiogram revealed no filling defects or evidence of a bile leak.
Figure 7.
Stent-related changes were observed with direct cholangioscopic visualization in the right anterior hepatic duct.
Figure 8.
A clean-based ulcer with heaped-up mucosal edges was noted at the site of distal stent impaction after stent removal.
Outcome
The proximally migrated plastic biliary stent was successfully removed with ERCP and direct visualization with cholangioscopy using a retrieval snare through the working channel of the cholangioscope. This is another tool that can be considered for inwardly migrated stents that cannot be extracted using conventional ERCP techniques.
Disclosure
Dr Mullady is a consultant for Boston Scientific. All other authors disclosed no financial relationships.
Footnotes
If you would like to chat with an author of this article, you may contact Dr Weaver at weavermichael@wustl.edu.
Supplementary data
ERCP was performed and a proximally migrated biliary stent was noted in the right anterior hepatic duct. Retrieval of the stent was unsuccessful using traditional techniques including balloon traction, rat-toothed forceps, dilation balloon, Soehendra stent retriever, and lithotripsy basket. Successful removal was accomplished using single-operator cholangioscopy and a mini-snare.
References
- 1.Katsinelos P., Kountouras J., Paroutoglou G. Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers. Surg Laparosc Endosc Percutan Tech. 2009;19:217–221. doi: 10.1097/SLE.0b013e3181a031f5. [DOI] [PubMed] [Google Scholar]
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
ERCP was performed and a proximally migrated biliary stent was noted in the right anterior hepatic duct. Retrieval of the stent was unsuccessful using traditional techniques including balloon traction, rat-toothed forceps, dilation balloon, Soehendra stent retriever, and lithotripsy basket. Successful removal was accomplished using single-operator cholangioscopy and a mini-snare.