Self-expandable metal stents (SEMS) represent the preferred palliative management
of malignant biliary strictures [1]. They are relatively easy to insert and provide immediate drainage of the biliary
tract. Removal of a SEMS, sometimes considered necessary because of occlusion or malposition,
can be technically challenging [2]. In this report, we present a safe and easy method of removing a malpositioned biliary
SEMS.
A 62-year old woman presented with jaundice due to pancreatic cancer with liver metastases.
As she was unfit for surgery, an uncovered 80-mm SEMS (Biliary Wallstent; Boston Scientific,
Galway, Ireland) was inserted in the common bile duct. Four months later, the patient
presented with cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP)
was performed, and suggested tumor overgrowth within the SEMS. A second, 100-mm covered
SEMS (Shim-Hanaro; MI Tech, Seoul, Korea) was inserted through the previously placed
SEMS. Unfortunately, the covered SEMS was poorly positioned, with a large part of
the stent protruding into the duodenum ([Fig. 1]). A polypectomy snare (1.5 × 3 cm; Wilson-Cook Medical, Winston Salem, North Carolina,
USA) was advanced through a regular 10-Fr pushing catheter (Cook Ireland, Limerick,
Ireland), inserted through the accessory channel, and the duodenal end of the covered
SEMS was grasped ([Fig. 2]). By gentle pulling on the polypectomy snare, the SEMS slowly collapsed and could
be withdrawn inside the pushing catheter ([Fig. 3] and [Video 1]), which was subsequently withdrawn through the duodenoscope. Finally, an 80-mm uncovered
SEMS (Wallstent) was placed within the originally inserted SEMS, this time in a good
position ([Fig. 4]).
Fig. 1 Malpositioned covered self-expandable metal stent (SEMS) protruding into the duodenum.
Fig. 2 Polypectomy snare grasping the distal end of the malpositioned SEMS.
Fig. 3 SEMS being pulled inside the pushing catheter.
Fig. 4 Appearance after removal of the malpositioned stent and insertion of a second uncovered
SEMS.
Video
1 Extraction of a covered biliary self-expandable metal stent, using a polypectomy
snare and a pushing catheter.
Several techniques have been described for removing a biliary SEMS. Our technique
for removing a malpositioned SEMS has not been described before, is relatively easy,
and carries no risk of scope damage or intestinal perforation, since the wire filaments
at the distal end of the SEMS are covered within the pushing catheter.
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