Endoscopic ultrasound (EUS)-guided hepaticogastrostomy with a fully covered metal
stent is an option for malignant biliary obstruction after a failed endoscopic retrograde
cholangiopancreatography (ERCP) [1]
[2]
[3]; however, migration of the stent can be a fatal complication [3]
[4]. We report a case in which a migrated stent was successful reset using a foreign
body forceps.
A 73-year-old woman developed abdominal pain and fever on the third day after EUS-guided
hepaticogastrostomy with a metal stent (WallFlex Biliary RX, fully covered stent system;
Boston Scientific, Galway, Ireland). A computed tomography (CT) scan showed that stent
migration had occurred ([Fig. 1 a], [Fig. 1 b], [Fig. 1 c]) and an abdominal fluid collection had developed in the omental bursa ([Fig. 1 d]).
Fig. 1 Computed tomography (CT) scan images showing: a, b, c the migrated stent; d an abdominal fluid collection within the omental bursa.
We performed a puncture with a 19G flexible EUS aspiration needle (Expect; Boston
Scientific, Menomonie, Wisconsin, USA) and inserted a 0.035-inch guidewire (METII-35-480
Tracer Metro Direct Wire Guide; Cook Medical, Limerick, Ireland) through the migrated
stent, before enlarging the transmural tract by balloon dilation (Balloon dilation
catheter; Changzhou Jiuhong Medical Instrument Company Limited, Changzhou, China).
We then successfully reset the stent using a foreign body forceps (Rat tooth forceps;
Shanghai Alton Medical Instrument Company Limited, Shanghai, China), implanted a new
longer stent (10 mm × 80 mm) inside the original one, and inserted a drainage tube
(Liguory nasal biliary drainage catheter; Cook Medical) into the abdominal fluid collection
([Video 1]). The patient was discharged from the hospital 4 days later. The stents functioned
well for the following 2 months ([Fig. 2]).
Endoscopic ultrasound (EUS)-guided repositioning of a migrated metal stent: a 0.035-inch
guidewire is passed through the migrated stent via a 19G flexible EUS aspiration needle
and the transmural tract is enlarged by balloon dilation; the stent is successfully
repositioned using foreign body forceps and a new longer stent is implanted inside
the original; finally a drainage tube is inserted into the fluid collection.
Fig. 2 Computed tomography (CT) scan images approximately 2 months later showing the repositioned
stents still in place.
This case illustrates that the omental bursa is an appropriate anastomotic choice
for endoscopic operations. The abdominal fluid collection and migrated stent were
restricted to the omental bursa, which thereby reduced the risk of serious consequences
and facilitated endoscopic treatment. Therefore, we should learn to find the omental
bursa by recognizing important ligaments during EUS [5].
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