Endoscopic removal of a deteriorated fully-covered self-expandable metal stent using an endoscopic retrograde cholangiopancreatography guide sheath
Article information
A 73-year-old woman with unresectable pancreatic cancer underwent chemotherapy. A fully-covered self-expandable metal stent (FCSEMS) was inserted to the common bile duct because of a malignant bile duct stricture (Fig. 1A, B). Although chemotherapy was effective, she developed recurrent biliary obstruction and was admitted for FCSEMS replacement. Endoscopic retrograde cholangiopancreatography revealed a near-complete obstruction of the FCSEMS lumen (8 mm×8 cm, BONASTENT; Standard Sci-Tech Inc.), inserted over one year previously by sludge. We failed to remove the FCSEMS using a snare, with the lower end cover being removed during the extraction (Fig. 1C). Although unclear, the cause underlying this complication was attributed to the deterioration of the FCSEMS. A guide sheath system (UMIDAS Sheath Cannula; UMIDAS) was used to remove the FCSEMS and was inserted to the bile duct, and the tip of the FCSEMS was grasped using biopsy forceps (Radial Jaw 4P; Boston Scientific) (Fig. 2A). Subsequently, the stent was detached from the bile duct wall via inversion (Fig. 2B). The lower end of the stent was grasped using forceps and pulled into the endoscope for removal (Fig. 2C, Video 1). Upon removal, damage to the lower end cover of the FCSEMS and sludge accumulation were observed (Fig. 2D). The guide sheath system was initially developed for selective pancreaticobiliary biopsy.1 However, this system has reportedly been used to remove migrated or stray bile duct stents.2 Inversion techniques have been reported in removing migrated or difficult-to-remove metallic bile duct stents.3 This study reports the safe and stable retrieval of a difficult-to-remove deteriorated FCSEMS using inversion techniques through the guide sheath system.
(A, B) Fully-covered self-expandable metal stent (FCSEMS) on computed tomography. (C) FCSEMS with cover section damaged and metallic portion exposed.
(A) Biopsy forceps inserted through the guide sheath system. (B) Biopsy forceps grasping the upper end of the fully-covered self-expandable metal stent (FCSEMS) through inversion. (C) Successful FCSEMS removal. (D) Post- removal FCSEMS.
Video
Video 1. The endoscopic retrograde cholangiopancreatography guide sheath enables the removal of a deteriorated fully-covered self-expandable metal stent from the bile duct wall through inversion techniques.
A video related to this article can be found online at https://doi.org/10.5946/ce.2024.170.
Notes
Conflicts of Interest
Tsuyoshi Suda received an honorarium; he is a consultant for Zeon Corporation and delivered a lecture at Olympus Marketing and SB Kawasumi. The other authors have no potential conflicts of interest.
Funding
None.
Acknowledgments
Written consent was obtained from the patient.
Author Contributions
Conceptualization: TS; Data curation: TS; Investigation: TS, KS, MM, KK; Methodology: TS, KS; Project administration: TS; Supervision: KA, ST; Visualization: TS; Writing–original draft: TS; Writing–review & editing: all authors.