Endoscopy 2020; 52(09): E320-E321
DOI: 10.1055/a-1119-0987
E-Videos

Digital cholangioscopy-guided retrieval of a migrated hepaticogastrostomy stent through a created hepaticogastrostomy route

Tomotaka Saito
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Tsuyoshi Hamada
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Hirofumi Kogure
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Yousuke Nakai
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
2  Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Kazuhiko Koike
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
› Author Affiliations
 

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is increasingly utilized for benign biliary diseases in cases with surgically altered anatomy [1] [2], but stent migration is a potential complication [3]. 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 [4]. No procedure-related adverse event occurred.

Zoom Image
Fig. 1 A migrated hepaticogastrostomy stent in the bile duct at segment 2. The dotted line represents the gastric wall.
Zoom Image
Fig. 2 Retrieval of a migrated stent through a second hepaticogastrostomy fistula utilizing digital cholangioscopy. a The digital cholangioscope was advanced through a newly created hepaticogastrostomy fistula. b The migrated stent was grasped using a mini snare under digital cholangioscopic visualization. c The stent was successfully withdrawn to the stomach. d Fluoroscopic image of the biliary tree after removal of the stent and intrahepatic biliary stones.

Video 1 Retrieval of a migrated stent through a second hepaticogastrostomy fistula utilizing digital cholangioscopy.


Quality:

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 [5].

Endoscopy_UCTN_Code_CPL_1AK_2AI

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos


#

Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Yousuke Nakai, MD, PhD
Department of Endoscopy and Endoscopic Surgery
Graduate School of Medicine, The University of Tokyo
7-3-1 Hongo
Bunkyo-ku, Tokyo 113-8655
Japan   
Fax: +81-3-58009801   

Publication History

Publication Date:
27 February 2020 (online)

© Georg Thieme Verlag KG
Stuttgart · New York


Zoom Image
Fig. 1 A migrated hepaticogastrostomy stent in the bile duct at segment 2. The dotted line represents the gastric wall.
Zoom Image
Fig. 2 Retrieval of a migrated stent through a second hepaticogastrostomy fistula utilizing digital cholangioscopy. a The digital cholangioscope was advanced through a newly created hepaticogastrostomy fistula. b The migrated stent was grasped using a mini snare under digital cholangioscopic visualization. c The stent was successfully withdrawn to the stomach. d Fluoroscopic image of the biliary tree after removal of the stent and intrahepatic biliary stones.