Retrieval of a Dislocated Plastic Stent from the Ductus Hepaticus Dexter using a new Balloon System

A 58-year-old man presented with a history of dislocated plastic biliary endoprothesis in November 2003 in our hospital. The endoprothesis (Tytgat 9 mm 8.5 F) was inserted in August 2002 in a peripheral hospital because of “recurrent jaundice and cholangitis and suspected choledochocele”. Two months later an ERCP showed migration of the stent into the right hepatic duct. Four subsequent attempts at retrieving the endoprothesis in 3 different hospitals failed. Reasons for failure were “inability to place or open a forceps within the small hepatic duct” and “inability to reach the endoprothesis in the right bile duct with a basket or Soehendra retriever”.

On admission to our hospital the patient denied any abdominal pain, there was no jaundice or fever, laboratory tests showed no cholestasis but there was slight inflammation confirmed by measurement of C-reactive protein (5.0 mg% normal < 0.3 mg%). We decided to make a new attempt to extract the stent due to the well-known risks of stent dislocations in the bile duct system such as cholangitis, bleeding and perforation [1].

After cannulating the common bile duct and injecting contrast into the bile duct system the endoprothesis was localized completely in the ductus hepaticus dexter. A guide wire (Jagwire super stiff 0.035 in. Boston Scientific, Germany) was inserted into the right hepatic duct beneath the migrated plastic stent. Thereafter a balloon (Extractor C, RX, 9 - 12 mm, Boston Scientific, Germany) was introduced over the wire to the proximal end of the plastic stent, inflated carefully to the first diameter (9 mm) and then retracted slowly. With repeated maneuvers of placing the balloon at the proximal end of the endoprothesis and gradually inflating the balloon to its second diameter (12 mm), a retraction through the papilla duodeni major was achieved (Fig. [1]). Finally the stent was extracted with a standard polypectomy snare in total without further complications. The cholangiogram after extraction showed no abnormalities. The patient, who was treated on an out-patient basis, left the hospital 4 hours later. The follow-up (6 weeks) was uneventful.

Fig. 1 Stent with balloon - passage through the papilla.

Proximal biliary retraction of plastic stents is a well-known complication of interventional biliary endoscopy [1]. As severe complications are possible, stent retrieval is recommended. In our case several attempts failed. Therefore, we used a new balloon device (Extractor C, RX, Boston Scientific, Germany) which allows the stepwise inflation of the balloon and has a significantly stiffer shaft than the standard balloon systems. In comparison to the standard approach the importance of this new technique needs to be evaluated in other indications. This case shows that a widespread knowledge and skill, including the use of forceps, baskets, balloons, the so-called Soehendra retriever and transhepatic procedures [2] in the handling of proximally migrated stents is necessary and that - in accordance with the literature - surgical procedures can usually be avoided [3] .

References

• 1 1 C haurasia OP, Rauws E A, Fockens P. et al . Endoscopic techniques for retrieval of proximally migrated biliary stents: the Amsterdam experience.  Endoscopy. 1999;  50 780-785
• 2 2 G upta A, Frazer C, Brennan F. Percutaneous retrieval of a proximally migrated common bile duct endoprosthesis from the right anterior duct.  Radiology. 2002;  46 325-328
• 3 Alfredo G, Raul A, Barinagarrementeria R. et al . Proximal migration of biliary prosthesis. Endoscopic extraction techniques.  Rev Gastroenterol Mex. 2001;  66 22-26