Clin Endosc.  2013 Jul;46(4):418-422.

Endoscopic Removal of a Proximally Migrated Metal Stent during Balloon Sweeping after Stent Trimming

• Cho NJ
• Lee TH
• Park SH
• Lee HM
• Hyun KH
• Lee SH
• Chung IK
• Kim SJ

Abstract

Placement of a self-expanding metal stent (SEMS) is an effective method for palliation of a malignant biliary obstruction. However, metal stents can cause various complications, including stent migration. Distally migrated metal stents, particularly covered SEMS, can be removed successfully in most cases. Stent trimming using argon plasma coagulation may be helpful in difficult cases despite conventional methods. However, no serious complications related to the trimming or remnant stent removal method have been reported due to the limited number of cases. In particular, proximal migration of a remnant fragmented metal stent after stent trimming followed by balloon sweeping has not been reported. We report an unusual case of proximal migration of a remnant metal stent during balloon sweeping following stent trimming by argon plasma coagulation. The remnant metal stent was successfully removed with rotation technique using a basket and revised endoscopically.

Keyword

Pancreatic neoplasms; Stents; Cholangiopancreatography, endoscopic retrograde; Argon plasma coagulation

MeSH Terms

Argon Plasma Coagulation
Cholangiopancreatography, Endoscopic Retrograde
Pancreatic Neoplasms
Stents

Figure

• 

  Fig. 1 Endoscopic retrograde cholangiopancreatography findings. (A) About 1.5-cm-long short segmental distal common bile duct narrowing with upstream bile duct dilatation. (B) Diffuse irregular narrowing of the pancreatic duct (PD) with marked upstream PD dilatation.

• 

  Fig. 2 Duodenoscopic findings. (A) Partial distally migrated biliary covered self-expanding metal stent (cSEMS). (B) Stent trimming by argon plasma coagulation. (C) Completely fragmented cSEMS stent after trimming.

• 

  Fig. 3 Endoscopic retrograde cholangiopancreatography findings. (A) The proximally migrated metal stent after trimming, and the guidewire passed through the migrated stent. (B) Two 7-Fr double-pigtail stents were inserted into both intrahepatic ducts through the migrated stent.

• 

  Fig. 4 Endoscopic retrograde cholangiopancreatography finding of migrated stent removal. (A) The proximally migrated stent was floating in the common bile duct and was captured with a Dormia basket. (B) The proximal portion of the floating stent was captured by the basket and then rotated 180° in the common bile duct. (C) The stent was retrieved from its proximal end after complete rotation.

• 

  Fig. 5 Gross appearance of the proximally migrated amputated covered self-expanding metal stent.

Reference

1. Davids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet. 1992; 340:1488–1492. PMID: 1281903.

2. Kahaleh M, Tokar J, Conaway MR, et al. Efficacy and complications of covered Wallstents in malignant distal biliary obstruction. Gastrointest Endosc. 2005; 61:528–533. PMID: 15812404.

3. Pescatore P, Meier-Willersen HJ, Manegold BC. A severe complication of the new self-expanding spiral nitinol biliary stent. Endoscopy. 1997; 29:413–415. PMID: 9270926.

4. Thumbe VK, Houghton AD, Smith MS. Duodenal perforation by a Wallstent. Endoscopy. 2000; 32:495–497. PMID: 10863921.

5. Roebuck DJ, Stanley P, Katz MD, Parry RL, Haight MA. Gastrointestinal hemorrhage due to duodenal erosion by a biliary wallstent. Cardiovasc Intervent Radiol. 1998; 21:63–65. PMID: 9473549.

6. Ishii K, Itoi T, Sofuni A, et al. Endoscopic removal and trimming of distal self-expandable metallic biliary stents. World J Gastroenterol. 2011; 17:2652–2657. PMID: 21677835.

7. Shin HP, Kim MH, Jung SW, et al. Endoscopic removal of biliary self-expandable metallic stents: a prospective study. Endoscopy. 2006; 38:1250–1255. PMID: 17163328.

8. Familiari P, Bulajic M, Mutignani M, et al. Endoscopic removal of malfunctioning biliary self-expandable metallic stents. Gastrointest Endosc. 2005; 62:903–910. PMID: 16301035.

9. Kahaleh M, Tokar J, Le T, Yeaton P. Removal of self-expandable metallic Wallstents. Gastrointest Endosc. 2004; 60:640–644. PMID: 15472699.

10. Christiaens P, Decock S, Buchel O, et al. Endoscopic trimming of metallic stents with the use of argon plasma. Gastrointest Endosc. 2008; 67:369–371. PMID: 18226706.

11. Vanbiervliet G, Piche T, Caroli-Bosc FX, et al. Endoscopic argon plasma trimming of biliary and gastrointestinal metallic stents. Endoscopy. 2005; 37:434–438. PMID: 15844021.

12. Bakhru M, Ho HC, Gohil V, et al. Fully-covered, self-expandable metal stents (CSEMS) in malignant distal biliary strictures: mid-term evaluation. J Gastroenterol Hepatol. 2011; 26:1022–1027. PMID: 21299614.

13. Ho H, Mahajan A, Gosain S, et al. Management of complications associated with partially covered biliary metal stents. Dig Dis Sci. 2010; 55:516–522. PMID: 19267200.

14. Levy MJ, Wiersema MJ. Endoscopic removal of a biliary Wallstent with a suture-cutting device in a patient with primary pancreatic lymphoma. Endoscopy. 2002; 34:835–837. PMID: 12244508.

15. Chen YK, Jakribettuu V, Springer EW, Shah RJ, Penberthy J, Nash SR. Safety and efficacy of argon plasma coagulation trimming of malpositioned and migrated biliary metal stents: a controlled study in the porcine model. Am J Gastroenterol. 2006; 101:2025–2030. PMID: 16848800.

16. Cho JH, Dong SH, Cho CH, et al. A case of argon plasma trimming of a biliary metallic stent causing a duodenal obstruction. Korean J Gastrointest Endosc. 2011; 42:195–200.

17. Katsinelos P, Kountouras J, Paroutoglou G, et al. Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers. Surg Laparosc Endosc Percutan Tech. 2009; 19:217–221. PMID: 19542849.

18. Chaurasia OP, Rauws EA, Fockens P, Huibregtse K. Endoscopic techniques for retrieval of proximally migrated biliary stents: the Amsterdam experience. Gastrointest Endosc. 1999; 50:780–785. PMID: 10570336.