Endoscopy 2014; 46(S 01): E58-E59
DOI: 10.1055/s-0033-1359163
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic salvage technique for spontaneous dislocation and tumor ingrowth of a partially covered, self-expandable metallic stent after endoscopic ultrasound-guided choledochoduodenostomy

Hiroshi Kawakami
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Masaki Kuwatani
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Kazumichi Kawakubo
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Taiki Kudo
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Yoko Abe
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Kimitoshi Kubo
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Naoya Sakamoto
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
› Author Affiliations
Further Information

Publication History

Publication Date:
12 February 2014 (online)

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has been established as an alternative method of biliary drainage after failure of endoscopic retrograde cholangiopancreatography (ERCP) [1] [2]. Because of its prolonged stent patency and reduced bile leakage, use of the covered self-expandable metallic stent (CSEMS) has recently been favored. We present a case of spontaneous dislocation of a partially covered SEMS (PCSEMS) after EUS-CDS that was successfully rescued by endoscopic intervention.

A 67-year-old woman with metastatic cancer of the pancreatic head was admitted to our hospital with obstructive jaundice. She underwent EUS-CDS using a PCSEMS (WallFlex stent, 10 × 60 mm; Boston Scientific Japan, Tokyo, Japan) without complication ([Video 1]). Seven months later, she developed acute cholangitis. The PCSEMS had dislocated, as was confirmed on computed tomography ([Fig. 1]). Our first attempt was to try to extract the PCSEMS using a snare, but this failed because of tumor ingrowth into the uncovered portion. In our next attempt, the PCSEMS was partially trimmed using argon plasma coagulation with an electrosurgical generator (ICC 200; Erbe Elektromedizin, Tübingen, Germany) at 80 W and with a flow rate of 2 L/min ([Fig. 2]), and we attempted guidewire cannulation through the partially fragmented PCSEMS. A 0.025-inch guidewire was advanced through the ERCP catheter under fluoroscopic guidance ([Video 2]). ERC revealed a stricture of the PCSEMS caused by tumor ingrowth ([Fig. 3], [Video 2]). An ERCP catheter and a biliary dilation catheter could not be passed through the stricture ([Video 2]). In our third attempt, we dilated the stricture using a 6-Fr wire-guided diathermic dilator (Cysto-Gastro-Set; Endo-Flex, Voerde, Germany) using an EGS-100 electrosurgical generator (Olympus, Tokyo, Japan; 30 W in pulse cut slow mode) ([Fig. 4], [Video 2]). Finally, a 6-Fr uncovered SEMS (Zilver 635 stent; 10 mm × 60 mm, Cook-Japan, Tokyo, Japan) was placed without complication ([Fig. 5], [Video 2]).

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Fig. 1 Radiograph 7 months after endoscopic ultrasound-guided choledochoduodenostomy in a 67-year-old woman, showing spontaneous dislocation of a partially covered self-expandable metallic stent.
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Fig. 2 Endoscopic image 7 months after endoscopic ultrasound-guided choledochoduodenostomy showing the partially covered self-expandable metallic stent trimmed using argon plasma coagulation.
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Fig. 3 Radiograph showing spontaneous dislocation of the partially covered self-expandable metallic stent and stricture of the stent due to tumor ingrowth.
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Fig. 4 Radiograph showing a 6-Fr diathermic dilator successfully advanced through the severe stricture over a guidewire under fluoroscopic guidance.
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Fig. 5 Radiograph showing placement of the uncovered self-expandable metallic stent in the stricture.


Quality:
Endoscopic ultrasound-guided choledochoduodenostomy using a partially covered self-expandable metallic stent.


Quality:
Endoscopic salvage technique for a severe stricture of a partially covered self-expandable metallic stent that was dilated using a 6-Fr diathermic dilator, followed by placement of an uncovered self-expandable metallic stent.

Spontaneous dislocation of a PCSEMS after EUS-CDS is a very rare complication [1] [2]. In the case described here, we successfully mitigated this situation using endoscopic intervention. In particular, a diathermic dilator is useful for dilating severe strictures [3] [4]. The findings described here suggest that more attention should be paid to the possibility of PCSEMS dislocation when performing EUS-CDS.

Endoscopy_UCTN_Code_CPL_1AL_2AD

 
  • References

  • 1 Itoi T, Isayama H, Sofuni A et al. Stent selection and tips on placement technique of EUS-guided biliary drainage: transduodenal and transgastric stenting. J Hepatobiliary Pancreat Sci 2011; 18: 664-672
  • 2 Kawakubo K, Isayama H, Kato H et al. Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage (EUS-BD) for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 11.09.2013; doi: DOI: 10.1002/jhbp.27. [Epub ahead of print]
  • 3 Kawakami H, Kuwatani M, Eto K et al. Resolution of a refractory severe biliary stricture using a diathermic sheath. Endoscopy 2012; 44 (Suppl. 02) E119-120
  • 4 Kawakami H, Kuwatani M, Kawakubo K et al. Transpapillary dilation of refractory severe biliary stricture or main pancreatic duct by using a wire-guided diathermic dilator (with video). Gastrointest Endosc 07.09.2013; DOI: 10.1016/j.gie.2013.07.055. [Epub ahead of print]