Endoscopy 2018; 50(11): 1129-1130
DOI: 10.1055/a-0666-4462
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Revision of migrated self-expandable metal stent by the remOVE device

Tiffany Chua
Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix Arizona, United States
,
Norio Fukami
Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix Arizona, United States
› Author Affiliations
Further Information

Corresponding author

Norio Fukami, MD
Therapeutic Endoscopy
Department of Gastroenterology and Hepatology
Mayo Clinic Arizona
5777 E. Mayo Blvd
Phoenix
Arizona 85054
United States   
Fax: +1-480-3018673   

Publication History

Publication Date:
14 August 2018 (eFirst)

 

Self-expandable metal stents (SEMS) provide longer patency duration compared with plastic stents for malignant biliary obstruction [1]. Tumor in-/overgrowth, and stent migration can cause reocclusion of the biliary tract. Herein we describe the revision of a distally migrated and stenosed biliary SEMS using the remOVE system (Ovesco Endoscopy, Tübingen, Germany), a device used to fragment and retrieve over-the-scope clips (OTSC) ([Video 1]).

Video 1 The Ovesco reMOVE device (Ovesco Endoscopy, Tübingen, Germany) may provide a safe and effective technique for revision of migrated self-expandable metal stents.

Georg Thieme Verlag. Please enable Java Script to watch the video.

A 62-year-old woman with pancreatic adenocarcinoma and biliary obstruction previously treated with SEMS presented with jaundice, abdominal pain, and fever, raising concerns for ascending cholangitis. Endoscopic retrograde cholangiopancreatography showed a distally migrated uncovered metal stent obstructing the duodenal lumen ([Fig. 1]). The cholangiogram showed a single, severe stenosis within the metal stent, which was likely due to tumor ingrowth in the lower third of the common bile duct. Reintervention with a metal stent was considered the best option.

Zoom Image
Fig. 1 Endoscopic retrograde cholangiopancreatography revealed that the old biliary stent had migrated distally, abutting the opposite duodenal wall. Granulation tissue was visible at the distal ends of the stent.

We proceeded with stent revision prior to placement of an additional SEMS. Thermal energy was applied using the remOVE system in order to fragment the braided wire. One to three applications of direct current from the DC Cutter were adequate to fragment and cut the wire. Trimming was completed within 12 minutes without any evident cautery effect on nearby tissue ([Fig. 2]). Placement of an additional SEMS was successful with proper extension length into the duodenum ([Fig. 3]).

Zoom Image
Fig. 2 The redundant portion of the old stent was safely retrieved and removed from the patient.
Zoom Image
Fig. 3 A 10 × 60 mm metal stent was placed within the previous stent for therapy of recurrent malignant biliary stricture. Note that the distal ends of the new stent extend past the trimmed portion of the old stent in order to protect the surrounding tissue.

Nd:YAG laser and argon plasma coagulation have been used in the revision of migrated biliary stents; thermal injury to surrounding tissues is the most common complication [2] [3]. The remOVE system, which consists of a direct current cutting instrument and a protective cap to retrieve the OTSC, has been approved for use in the United States and European Union [4]. Direct current cutting confers an advantage over other methods as its current is conducted over metallic components only [3] [4]. Our experience suggests that this may be a safe and efficacious method of revising distally migrated SEMSs in malignant biliary obstruction.

Endoscopy_UCTN_Code_TTT_1AR_2AZ

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Competing interests

None


Corresponding author

Norio Fukami, MD
Therapeutic Endoscopy
Department of Gastroenterology and Hepatology
Mayo Clinic Arizona
5777 E. Mayo Blvd
Phoenix
Arizona 85054
United States   
Fax: +1-480-3018673   


Zoom Image
Fig. 1 Endoscopic retrograde cholangiopancreatography revealed that the old biliary stent had migrated distally, abutting the opposite duodenal wall. Granulation tissue was visible at the distal ends of the stent.
Zoom Image
Fig. 2 The redundant portion of the old stent was safely retrieved and removed from the patient.
Zoom Image
Fig. 3 A 10 × 60 mm metal stent was placed within the previous stent for therapy of recurrent malignant biliary stricture. Note that the distal ends of the new stent extend past the trimmed portion of the old stent in order to protect the surrounding tissue.