Extraction of covered metal stents has been previously described
[1]
[2]
[3]
[4]
[5]. We report the case of a young
patient in whom we removed two uncovered Wallstents that had been placed in the
left and right liver lobes because of an unresectable Klatskin tumor 6 years
earlier.
The 36-year-old woman presented with icterus and gallbladder stones
in 2002. Extensive work-up including CT, MRI, endoscopic ultrasonography,
positron emission tomography, and laparotomy with histological study of the
lesion concluded in the diagnosis of a Klatskin tumor invading the inferior
vena cava with metastases in the liver. The patient underwent palliative
treatment with placement of two Wallstents and gemcitabine chemotherapy for 1
year.
In 2007 she presented with recurrent cholangitis and obstruction of
both stents ([Fig. 1]), which necessitated several
sessions of endoscopic retrograde cholangiography to extract stones ([Fig. 2]). Surprisingly, biliary brush specimens
lacked any signs of malignancy and therefore put in question the diagnosis of
malignancy in favor of one of inflammatory pseudotumor.
After consideration of total surgical common bile duct and stent
excision as opposed to endoscopic retrieval, we decided for an endoscopic
approach. Extraction was performed in two sessions (taking 1.5 hours and 2
hours respectively). The chosen approach was a wire-by-wire extraction after an
unsuccessful attempt to grasp the stents in a snare. Multiple devices were
used: endoscopic rat-tooth and crocodile forceps ([Fig. 3]), snares, and several Dormia baskets, the
most useful being the rat-tooth forceps.
Prior to the extraction of the second Wallstent, which was
completely embedded in the bile ducts, a covered Wallstent was inserted into
the preexisting uncovered stent to decrease the endoluminal hyperplasia ([Fig. 4]). The covered stent was easily retrieved with
a monofilament mucosectomy snare, and wire-by-wire extraction of the last stent
was then successful ([Fig. 5]). No complications
were reported, and control MRI at 6-month follow-up showed good clearance of
the bile duct with no intrahepatic strictures ([Fig. 6]).
Fig. 1 Magnetic resonance (MR)
cholangiography showing obstruction of both Wallstents completely embedded in
the bile duct walls.
Fig. 2 Endoscopic retrograde
cholangiopancreatography (ERCP) image confirming obstruction of the
Wallstents.
Fig. 3 Wire-by-wire extraction
of the first stent with rat-tooth forceps.
Fig. 4 Insertion of a covered
metal stent into the second embedded stent to decrease intraluminal endothelial
hyperplasia.
Fig. 5 ERCP image showing
complete extraction without bile leakage or strictures.
Fig. 6 MR cholangiography at
6-month follow-up showing good clearance of the extrahepatic and intrahepatic
bile ducts.
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