Retrieval of a migrated stent during endoscopic ultrasound-guided drainage of duodenal diverticular abscess

Endoscopic ultrasound (EUS)-guided drainage for an abdominal abscess has become recognized as a minimally invasive alternative to surgery. With regard to EUS-guided drainage of a pancreatic pseudocyst, the occurrence of stent migration into the pseudocyst is a relatively rare complication [1] and can be prevented by using double-pigtail stents [2]. This report describes endoscopic retrieval of a migrated double-pigtail stent during EUS-guided drainage of duodenal diverticular abscess.

A 91-year-old woman with upper right abdominal pain and fever was referred to our hospital. Computed tomography showed a duodenal diverticular abscess ([Fig. 1]). Therefore, EUS-guided drainage of the abscess was performed.

Fig. 1 Computed tomography showed a duodenal diverticular abscess, with air-fluid level.

The abscess was punctured with a 19-gauge needle, and a 0.025-inch guidewire was placed. Subsequently, an additional guidewire was placed using a triple-lumen catheter (Haber RAMP catheter; Cook Japan, Tokyo, Japan) ([Fig. 2 a]). A 7-Fr double-pigtail stent was placed over the wire. However, before the nasobiliary drainage tube could be placed, the stent accidentally jumped into the abscess ([Fig. 2 b]).

Fig. 2 Radiographic images. a Two guidewires were placed within the abscess using a triple-lumen catheter. b A 7-Fr double-pigtail stent accidentally jumped into the abscess. c A basket catheter grasped the tip of the migrated stent. d A 7-Fr double-pigtail stent and a 7-Fr nasobiliary drainage tube were placed successfully.

We opted to retrieve the migrated stent using a basket catheter. First, the triple-lumen catheter was inserted over the remaining guidewire to place an additional guidewire. Then, a basket catheter (FG-V435P; Olympus Medical Systems Corp., Tokyo, Japan) was introduced into the abscess over the guidewire, and the migrated stent was removed by grasping its tip with the basket catheter ([Fig. 2 c], [Video 1]). Finally, a 7-Fr double-pigtail stent and a 7-Fr nasobiliary drainage tube were placed successfully ([Fig. 2 d]).

Retrieval of a migrated stent using endoscopic ultrasound scope with a basket catheter under fluoroscopy.

The endoscopic retrieval of a migrated stent is technically challenging. In a few cases of pancreatic pseudocyst, migrated stents have been removed by forceps using a forward-viewing endoscope [3] [4] [5]. In our patient, the migrated stent was successfully retrieved by EUS scope using a basket catheter under fluoroscopy. Furthermore, it is important to place an additional guidewire during the procedure in case a guidewire slips out.

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• References

• 1 Varadarajulu S, Christein JD, Wilcox CM. Frequency of complications during EUS-guided drainage of pancreatic fluid collections in 148 consecutive patients. J Gastroenterol Hepatol 2011; 26: 1504-1508
• 2 Cahen D, Rauws E, Fockens P et al. Endoscopic drainage of pancreatic pseudocysts: long-term outcome and procedural factors associated with safe and successful treatment. Endoscopy 2005; 37: 977-983
• 3 Kahaleh M, Shami VM, Conaway MR et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy 2006; 38: 355-359
• 4 Varadarajulu S. EUS-guided retrieval of a migrated transgastric pancreatic stent. Endoscopy 2007; 39: E18-19
• 5 Lin L-F, Tung J-N. Difficult endoscopic retrieval of a migrated stent inside a pseudocyst. Case Rep Gastroenterol 2008; 2: 199-202