Digital cholangioscopy-guided retrieval of a migrated hepaticogastrostomy stent through a created hepaticogastrostomy route
Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is increasingly utilized for benign biliary diseases in cases with surgically altered anatomy  , but stent migration is a potential complication . We describe successful retrieval of a migrated hepaticogastrostomy stent through a newly created EUS-HGS route using a digital cholangioscope.
A 71-year-old man with a history of extended right hepatectomy for cholangiocarcinoma was referred for treatment of intrahepatic biliary stones. As stone extraction under enteroscope-assisted endoscopic retrograde cholangiopancreatography at an outside hospital failed due to multiple intrahepatic stones, we decided to perform EUS-HGS.
After plastic stent placement in the bile duct at segment 2, stone extraction was attempted through the fistula during the second session. Stone extraction was incomplete due to technical difficulty and large stone size, and therefore we planned to perform extracorporeal shock wave lithotripsy using a nasobiliary catheter. During nasobiliary catheter insertion following placement of a 7-Fr straight-type plastic stent as HGS, we discovered that the stent had migrated into the fistula tract due to interference between the two tubes ([Fig. 1]). Although there was no risk of bile peritonitis thanks to the mature fistula, additional EUS-HGS in segment 3 was performed to prevent cholangitis. After fistula maturation, the fistula was dilated using a balloon catheter, and a digital cholangioscope (SpyGlass DS; Boston Scientific Japan, Tokyo, Japan) was inserted ([Fig. 2], [Video 1]). Under direct visualization, the migrated stent was readily grasped using a dedicated mini snare (SpySnare, Boston Scientific) and successfully retrieved. Finally, stones were extracted using electrohydraulic lithotripsy under direct cholangioscopic visualization . No procedure-related adverse event occurred.
Video 1 Retrieval of a migrated stent through a second hepaticogastrostomy fistula utilizing digital cholangioscopy.
Although stent dislocation can be a serious complication during interventional EUS and may need a surgical intervention, cholangioscopy-guided removal of a migrated stent through another route can be a nonsurgical salvage option, as we previously reported in EUS-guided pancreatic duct drainage .
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27 February 2020 (online)
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