Endoscopic Removal of a Proximally Migrated Metal Stent during Balloon Sweeping after Stent Trimming
A 74-year-old woman was admitted due to jaundice and epigastric pain which lasted for 7 days. Laboratory tests revealed the following: white blood cell count, 5.84×109/L (reference range, 4.0 to 10.8×109/L); aspartate aminotransferase, 123 IU/L; alanine aminotransferase, 144 IU/L; total bilirubin, 5.2 mg/dL; alkaline phosphatase, 488 IU/L; amylase, 315 U/L; lipase, 689 U/L; carbohydrate antigen 19-9, 35.86 U/mL; and carcinoembryonic antigen, 1.65 ng/mL. An abdominal computed tomography scan showed a ~2.1-cm low-attenuated mass lesion abutting on the superior mesenteric vein with dilatation of the intrahepatic bile duct, common bile duct (CBD) and pancreatic duct (PD), which suggested pancreas neoplasm. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed short segmental distal CBD narrowing and diffuse irregular narrowing of the PD with marked upstream ductal dilatation (). After a 5-Fr single pigtail 7-cm-long stent was inserted into the PD following brushing cytology and an 8.5-Fr Tannenbaum, 7-cm-long (Cook Endoscopy, Winston-Salem, NC, USA) stent was inserted into the CBD, her symptoms improved and the obstructive jaundice resolved. Finally, we diagnosed her as a pancreas adenocarcinoma with CBD obstruction.\nTwo months later, she underwent repeat ERCP for stent exchange using a 60-mm-long, 10-mm diameter cSEMS (Bonastent; Standard Sci Tech Inc., Seoul, Korea), because she refused surgical operation. However, she was readmitted in 2 months due to epigastric pain, fever, and jaundice. A subsequent endoscopy showed a partial distally migrated cSEMS that was impossible to access and revise through the migrated stent. We decided to remove the stent but failed with forceps and a snare.\nThus, stent trimming was performed with an APC system (ERBE Elektromedizin GmbH, Tübingen, Germany). The power setting was 60 W, and the argon gas flow was set to 2 L/min. The amputated stump margin was set about 10 mm from the papilla. Stent amputation progressed in a circumferential manner until it was completely cut after 10 minutes (). The stent fragment was removed with a retrieval net. Then, a retrieval balloon was used to remove the clogging sludge following insertion of a guidewire through the remnant fragmented stent. However, while moving the balloon back and forth, the remnant stent migrated proximally very abruptly and floated to the dilated CBD. Immediate retrieval of the stent was not attempted because of the sharp cutting plane edge. Two 7-Fr double pigtail stents (9- and 10-cm long, respectively; Cook Endoscopy) were inserted in both intrahepatic bile ducts through the proximally migrated metal stent (). However, the patient was readmitted twice because of cholangitis and obstructive jaundice after 1 month, so removal of the proximally migrated metal stent was planned. Following removal of the double pigtail stent with rat tooth forceps, the stricture was dilated to 8 mm with a balloon catheter (Hurricane biliary balloon dilatation catheter; Boston Scientific, Natick, MA, USA). The proximal end of the floating metal stent was captured with a basket, rotated 180° in the CBD, and then removed successfully (, ). No procedure related complications occurred during the removal of the migrated stent, and then a uSEMS was inserted successfully. Since then, no complications have been observed for 5 months.