Salvage technique for covered metal stent migration during endoscopic reintervention after endoscopic ultrasound-guided hepaticogastrostomy

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) is an alternative drainage method for malignant biliary obstruction (MBO) when endoscopic retrograde cholangiopancreatography (ERCP) has failed [1]. A partially covered self-expandable metal stent (PCSEMS) is often used for EUS-HGS, but it cannot be removed. A new metal or plastic stent is therefore placed as endoscopic reintervention following EUS-HGS [2] [3] [4]; however, troubleshooting after endoscopic reintervention remains problematic because of a paucity of reported cases.

An 81-year-old woman who had previously undergone ERCP for MBO due to pancreatic cancer presented with recurrent biliary obstruction and duodenal stricture. An EUS-HGS using a PCSEMS (EGIS biliary stent, double-covered, 8 mm × 12 cm; S&G Biotech Inc., Yongin, South Korea) and duodenal stent placement were successfully performed. After 5 months, the patient underwent endoscopic reintervention for recurrent biliary obstruction. An additional fully covered SEMS (FCSEMS; HANAROSTENT benefit, 8 mm × 8 cm; Boston Scientific Co., Tokyo, Japan) was deployed through the stent mesh of the EUS-HGS PCSEMS because of the difficulty removing the PCSEMS, along with placement of an antegrade stent across the MBO ([Fig. 1]). A second endoscopic reintervention was required for SEMS occlusion, during which new plastic stents (Through & Pass Type-IT; Gadelius Medical, Tokyo, Japan) were placed through the distal end of the EUS-HGS SEMS after the stent mesh had been broken using argon plasma coagulation ([Fig. 2]).

Fig. 1 Fluoroscopic image showing endoscopic reintervention for recurrent biliary obstruction. Because the partially covered self-expandable metal stent (PCSEMS) inserted for endoscopic ultrasound-guided hepatogastrostomy (EUS-HGS) was not removed, an additional SEMS (black arrow) was deployed through the stent mesh of the EUS-HGS PCSEMS, with an additional antegrade stent placed across the malignant biliary obstruction (white arrow).

Fig. 2 During a second endoscopic reintervention for self-expandable metal stent occlusion, new plastic stents were placed through the distal end of the endoscopic ultrasound-guided hepatogastrostomy (EUS-HGS) self-expandable metal stent (SEMS), after the stent mesh had been broken by argon plasma coagulation, because of the difficulty removing the EUS-HGS SEMS.

After 2 months, the patient developed acute cholangitis due to migration of the EUS-HGS SEMS placed during the first endoscopic reintervention and cholecystitis due to the antegrade SEMS. After the plastic stents had been removed, grasping forceps (Rat Tooth; Olympus, Tokyo, Japan) were inserted via the EUS-HGS SEMS. The migrated SEMS was grabbed ([Fig. 3] a) and removed. Additionally, the antegrade SEMS was firmly grasped and gradually removed via the EUS-HGS route ([Fig. 3] b; [Video 1]). The successful removal of the two SEMSs was followed by the insertion of new plastic stents and the patient’s cholangitis and cholecystitis subsequently improved.

Fig. 3 Fluoroscopic images showing: a the migrated self-expandable metal stent (SEMS) in the left intrahepatic bile duct being grasped with grasping forceps and removed via the hepaticogastrostomy; b the antegrade SEMS in the common bile duct being grasped with grasping forceps and gradually removed via the hepaticogastrostomy.

Endoscopic removal of a migrated self-expandable metal stent (SEMS) and antegrade SEMS using grasping forceps via the hepaticogastrostomy route.Video 1

This technique demonstrates successful troubleshooting of endoscopic reintervention after EUS-HGS.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Moole H, Bechtold ML, Forcione D. et al. A meta-analysis and systematic review: Success of endoscopic ultrasound guided biliary stenting in patients with inoperable malignant biliary strictures and a failed ERCP. Medicine (Baltimore) 2017; 96: e5154
• 2 Minaga K, Kitano M, Uenoyama Y. et al. Feasibility and efficacy of endoscopic reintervention after covered metal stent placement for EUS-guided hepaticogastrostomy: A multicenter experience. Endosc Ultrasound 2022; 11: 478-486
• 3 Yane K, Katanuma A, Maguchi H. et al. Successful reintervention with metal stent trimming using argon plasma coagulation after endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2014; 46: E391-E392
• 4 Takenaka M, Minaga K, Yoshikawa T. et al. Novel concept using a plastic stent for endoscopic ultrasound-guided hepaticogastrostomy adjusting the length according to the patientʼs anatomy. Endoscopy 2019; 51: E362-E363

Publication History

Article published online:
17 January 2024