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HOME > Clin Endosc > Volume 59(4); 2026 > Article
Video of Issue Removal of embedded fully covered self-expandable metal stents above benign biliary strictures: the peel technique
Rosario Arena1orcid, Annasara Diotaiuti1orcid, Tommaso Antenucci2orcid, Chiara Distabile1orcid, Emilio Barbera2orcid, Riccardo Solimando1orcid
Clinical Endoscopy 2026;59(4):665-666.
DOI: https://doi.org/10.5946/ce.2025.236
Published online: November 20, 2025

1Department of Gastroenterology and GI Endoscopy, Universitaria di Ferrara Arcispedale S.Anna, Ferrara, Italy

2Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

Correspondence: Rosario Arena Department of Gastroenterology and GI Endoscopy, Universitaria di Ferrara Arcispedale S.Anna, Via Aldo Moro, 8, 44124, Ferrara FE, Italy E-mail: Rosario.arena84@gmail.com
• Received: July 16, 2025   • Revised: August 2, 2025   • Accepted: August 3, 2025

© 2026 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Fully covered self-expandable metal stents (FC-SEMSs) are increasingly employed in the management of benign biliary strictures owing to their removability and efficacy in maintaining ductal patency.1 Despite these advantages, cases involving difficult stent retrieval have been reported, often requiring advanced endoscopic techniques. Among these, the “stent-in-stent” approach is the most commonly described technique.2 However, this method requires the placement of a second stent, subsequent hospital admission, and repeat endoscopic intervention, thereby increasing both patient burden and procedural costs.
We report the case of a 70-year-old man who underwent the placement of a 60×10 mm FC-SEMS for a benign distal biliary stricture (Fig. 1). Six months later, the scheduled removal failed despite numerous retrieval attempts with both rat-tooth forceps and a polypectomy snare due to hyperplastic tissue overgrowth.
Therefore, a 0.025-inch guidewire was carefully advanced into the narrow space between the stent and the bile duct wall and gently navigated into the intrahepatic biliary tree. A Fogarty balloon catheter was subsequently introduced over the guidewire into the hepatic hilum to exclude false tract formation (Figs. 2, 3, Video 1). The balloon catheter was then rotated circumferentially around the stent to mechanically separate the stent and the hyperplastic tissue of the bile duct wall. The stent was then easily retrieved using a standard snare without the need for maneuvering. No adverse events were reported.
This case highlights an alternative and effective technique for retrieving embedded FC-SEMSs in benign biliary strictures, potentially avoiding the need for the stent-in-stent approach and its associated drawbacks.

Video 1.

Removal of the embedded full covered metal stent using the peel technique.
A video related to this article can be found online at https://doi.org/ce.2025.236.
Fig. 1.
Radiologic image of the fully covered metal stent into bile duct.
ce-2025-236f1.jpg
Fig. 2.
A guidewire was advanced into the narrow space between the stent and the bile duct wall and gently navigated into the intrahepatic biliary tree.
ce-2025-236f2.jpg
Fig. 3.
A Fogarty balloon catheter was introduced over the guidewire, with its tip advanced to the hepatic hilum to exclude the possibility of false tract formation.
ce-2025-236f3.jpg
  • 1. Devière J, Nageshwar Reddy D, Püspök A, et al. Successful management of benign biliary strictures with fully covered self-expanding metal stents. Gastroenterology 2014;147:385–395.ArticlePubMed
  • 2. Tringali A, Blero D, Boškoski I, et al. Difficult removal of fully covered self expandable metal stents (SEMS) for benign biliary strictures: the "SEMS in SEMS" technique. Dig Liver Dis 2014;46:568–571.ArticlePubMed

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        Removal of embedded fully covered self-expandable metal stents above benign biliary strictures: the peel technique
        Clin Endosc. 2026;59(4):665-666.   Published online November 20, 2025
        DOI: https://doi.org/10.5946/ce.2025.236
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      Removal of embedded fully covered self-expandable metal stents above benign biliary strictures: the peel technique
      Image Image Image
      Fig. 1. Radiologic image of the fully covered metal stent into bile duct.
      Fig. 2. A guidewire was advanced into the narrow space between the stent and the bile duct wall and gently navigated into the intrahepatic biliary tree.
      Fig. 3. A Fogarty balloon catheter was introduced over the guidewire, with its tip advanced to the hepatic hilum to exclude the possibility of false tract formation.

      Fig. 1.

      Fig. 2.

      Fig. 3.

      Removal of embedded fully covered self-expandable metal stents above benign biliary strictures: the peel technique
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