Spontaneous intraductal stent migration after endoscopic ultrasound-guided choledochogastrostomy

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative method of biliary decompression [1]. EUS-guided choledochogastrostomy (EUS-CGS) is considered a possible salvage therapy for patients in whom EUS-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) is not possible [2]. We report a case of intraductal migration of a partially-covered self-expandable metallic stent (PCSEMS) after EUS-CGS, which was managed successfully with endoscopic intervention.

A 56-year-old woman with locally advanced cancer of the pancreatic head was admitted to our hospital. She had previously undergone a gastrojejunostomy and percutaneous biliary drainage for malignant gastric outlet obstruction and biliary obstruction at another hospital. Given her strong desire to have the external drainage tube removed and because EUS-CDS and EUS-HGS were impossible for anatomical reasons, she underwent EUS-CGS with insertion of a PCSEMS for internal biliary drainage without complications ([Fig. 1]; [Video 1]).

Fig. 1 Abdominal radiograph showing a partially covered self-expanding metal stent in position between the extrahepatic bile duct and the gastric antrum.

Endoscopic ultrasound-guided choledochogastrostomy (EUS-CGS) using a partially-covered self-expandable metallic stent (PCSEMS).

The external drainage tube was removed successfully 15 days after EUS-CGS, but 1 month later she developed acute cholangitis. An emergency endoscopy revealed that the PCSEMS had migrated into the bile duct ([Fig. 2]), which was confirmed on an abdominal radiograph ([Fig. 3]). The remaining fistula was successfully cannulated and a guidewire was advanced through the migrated PCSEMS into the intrahepatic bile duct. Another PCSEMS was placed across the fistula between the first PCSEMS and the stomach ([Fig. 4]; [Video 2]). The cholangitis subsided and she was discharged 3 days after the procedure without complications.

Fig. 2 Endoscopic view 1 month after formation of the choledochogastrostomy showing the partially covered self-expanding metal stent that had migrated into the bile duct.

Fig. 3 Abdominal radiograph showing the distal end of the partially-covered self-expandable metallic stent located inside the fistula.

Fig. 4 Abdominal radiograph showing a second partially-covered self-expandable metallic stent (PCSEMS) placed across the fistula between the first PCSEMS and the stomach.

Placement of a second partially-covered self-expandable metallic stent (PCSEMS), which was positioned across the fistula between the first PCSEMS and the stomach.

Spontaneous intraductal migration of a covered metallic stent after EUS-BD is a serious complication [3]. We managed this successfully with endoscopic placement of a further PCSEMS across the resulting fistula. Because the extrahepatic bile duct and gastric antrum are not connected anatomically, we must be aware of this complication after EUS-CGS.

Endoscopy_UCTN_Code_CPL_1AK_2AJ

Competing interests: None

• References

• 1 Isayama H, Nakai Y, Kawakubo K et al. Recent progress in endoscopic ultrasonography guided biliary intervention. Clin J Gastroenterol 2012; 2: 93-100
• 2 Artifon EL, Okawa L, Takada J et al. EUS-guided choledochoantrostomy: an alternative for biliary drainage in unresectable pancreatic cancer with duodenal invasion. Gastrointest Endosc 2011; 73: 1317-1320
• 3 Martins FP, Rossini LG, Ferrari AP. Migration of a covered metallic stent following endoscopic ultrasound-guided hepaticogastrostomy: fatal complication. Endoscopy 2010; 42: E126-E127