Endoscopic sphincterotomy and stone extraction are widely performed as a primary intervention
for patients with common bile duct (CBD) stones, with or without cholangiosepsis,
with a high success rate and a relatively low complication rate [1]. When CBD stone removal is not successful, a plastic stent can be placed as a salvage
therapy to achieve drainage, especially in the septic patient. It has also been shown
that placement of biliary plastic stent prevents stone impaction and cholangitis [2]. The most common problem is stent migration occurring up to 5 % proximal (into the
duct) and 6 % distal (out of the duct) [3]. Several techniques have been described to retrieve inward migrated stents with
high success rates [4]
[5]. However, sometimes the endoprosthesis ends up in a very tricky position where your
usual techniques might not be sufficient, as presented in the following case.
We present a case of a 90-year-old woman who presented to the emergency department
with acute abdominal pain in the right upper quadrant, jaundice, fever, tachycardia,
and hypotension. Computed tomography scan showed a large CBD stone with a dilated
biliary tree ([Fig. 1]). Under the working diagnosis of cholangiosepsis, intravenous fluids and antibiotics
were initiated and a quick endoscopic retrograde cholangiopancreatography (ERCP) under
conscious sedation (midazolam and fentanyl) was executed. After the endoscopic sphincterotomy
was performed, a large 13-mm CBD stone was observed, which could not be retrieved
with a basket/balloon. To ensure drainage, a 7-cm 10-Fr plastic endoprosthesis was
placed in the common bile duct. The patient recovered well after this procedure and
was discharged home after several days. An ERCP under deep sedation (propofol) was
scheduled for the stone extraction 2 months later.
Fig. 1 Coronal computer tomography showing a large common bile duct stone with dilated bile
ducts.
The previously placed endoprosthesis was not visible upon introduction. On fluoroscopy,
the 13-mm CBD stone was still in situ and the endoprosthesis appeared to be migrated
deeply inwards into the liver ([Fig. 2]). After dilatation of the ampulla, the CBD stone could be removed easily with an
extraction balloon. Thereafter, multiple attempts to grasp the inward migrated stent
were performed, however there was not enough grip to extract the stent ([Fig. 3]). Next, direct peroral cholangioscopy was used in an attempt to remove the stent
under direct sight using an extraction balloon and grasping forceps ([Fig. 4]). However, we found that the distal end of the stent was stuck with the flank of
the stent in the cystic duct.
Fig. 2 Fluoroscopic image showing large common bile duct stone with deeply inward migrated
plastic endoprosthesis.
Fig. 3 Fluoroscopic image showing an attempt to grab the plastic stent using a grasping
forceps.
Fig. 4 Direct peroral cholangioscopic image of attempt to remove the endoprosthesis with
a balloon catheter.
So now what? Using a 1-mm snare and a 0.025-inch guidewire (both through the same
2.4-mm working channel of the nasoendoscope), we finally succeeded in creating a grasping
method to capture the stent ([Video 1]). After tightening against the endoscope, the stent could be removed successfully
([Video 1]).
Video 1 Inward migrated plastic stent lodged in the cystic duct and liver hilum retrieved
via direct peroral cholangioscopy.
This case shows an inventive method for a very uncommon problem. However, it highlights
the endless possibilities that are available nowadays for endoscopic biliary interventions.
Endoscopy_UCTN_Code_CPL_1AK_2AD
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
