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CC BY 4.0 · Endoscopy 2023; 55(S 01): E790-E791
DOI: 10.1055/a-2094-9374
E-Videos

Troubleshooting for difficult removal of a stent delivery system after endoscopic ultrasound-guided hepaticogastrostomy

Takeshi Ogura
1   Endoscopic Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
2   Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
,
Taro Iwatsubo 
1   Endoscopic Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
2   Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
,
Jun Sakamoto
2   Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
,
Junichi Nakamura
2   Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
,
Masahiro Yamamura
2   Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
,
Hiroki Nishikawa
2   Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
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Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is now widely performed for patients in whom endoscopic retrograde cholangiopancreatography is unsuccessful [1] [2] [3] [4]. Various technical tips have been reported for preventing adverse events and improving the technical success rate before stent deployment. We herein describe a troubleshooting technique for difficult removal of the stent delivery system after EUS-HGS stent deployment.

A 77-year-old woman was admitted for treatment of obstructive jaundice due to unresectable hepatic hilar carcinoma. Multiple uncovered self-expandable metal stents (UCSEMSs) were inserted and systemic chemotherapy was attempted; however, recurrent biliary obstruction was observed after 6 months. Reintervention using UCSEMS was then performed for the left, anterior, and posterior bile ducts, but biliary obstruction recurred after 4 months. Further reintervention was successful for the right hepatic bile duct but failed for the left hepatic bile duct. Therefore, EUS-HGS was attempted.

The intrahepatic bile duct was punctured using a 19 G needle. After injection of contrast medium, a 0.025-inch guidewire was deployed. Tract dilation was performed using a drill dilator. An 8.5 Fr stent delivery system was inserted and the stent was successfully deployed (8 mm × 12 cm, Spring Stopper stent; Taewoong Medical, Seoul, South Korea) ([Fig. 1 a]). However, the stent delivery system could not be removed because of insufficient stent expansion ([Fig. 1 b]). Therefore, the stent delivery system was cut close to the patient’s mouth using pliers, and the echoendoscope was removed ([Fig. 2]). A duodenoscope was inserted and a guidewire was inserted into the biliary tract through the EUS-HGS stent. After balloon dilation at the site of insufficient stent expansion ([Fig. 3 a]), the stent delivery system was removed successfully without any adverse events ([Fig. 3 b], [Video 1]).

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Fig. 1 Endoscopic ultrasound-guided hepaticogastrostomy. a Stent deployment was successfully performed. b The stent delivery system could not be removed owing to insufficient stent expansion (arrows).
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Fig. 2 The stent delivery system was cut close to the patient’s mouth using pliers.
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Fig. 3 Removal of the delivery system. a After guidewire insertion, balloon dilation was performed at the site of insufficient stent expansion. b The stent delivery system was successfully removed.

Video 1 Troubleshooting procedure in cases of difficult removal of a stent delivery system due to insufficient stent expansion.


Quality:

In cases of difficult removal of a stent delivery system due to insufficient stent expansion, additional dilation at the site of insufficiency may enable removal of the system.

Endoscopy_UCTN_Code_CPL_1AL_2AD

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Publication History

Article published online:
12 June 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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