Subscribe to RSS
DOI: 10.1055/s-0034-1377388
Successful re-intervention with metal stent trimming using argon plasma coagulation after endoscopic ultrasound-guided hepaticogastrostomy
Publication History
Publication Date:
25 September 2014 (online)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/lookinside/thumbnails/10.1055-s-0034-1377388-1.jpg)
Recently, endoscopic ultrasound (EUS)-guided biliary drainage has been introduced as an alternative method after failed endoscopic biliary drainage, particularly in patients with a pre-existing duodenal obstruction [1] [2] [3]. A longer self-expandable metal stent (SEMS) is usually used for EUS-guided hepaticogastrostomy (EUS-HGS) to prevent stent migration. However, re-intervention after EUS-HGS is challenging because of the protrusion of the SEMS into the stomach. Metal stent trimming using argon plasma coagulation (APC) has been reported to be a useful option for stent-related complications such as dislocation [4] [5]. We report a case in which successful re-intervention after EUS-HGS was made possible by metal stent trimming using APC.
A nonagenarian woman with advanced ampullary cancer was admitted to our center. She had a history of endoscopic transpapillary bile duct stenting and duodenal stenting covering the papilla, followed by EUS-HGS with an 8-mm diameter, 12-cm long, silicone-covered nitinol braided stent, with a 1-cm uncovered portion at the proximal end (Niti-S biliary S-type; Taewoong Medical, Seoul, South Korea).
The patient developed recurrent cholangitis caused by sludge formation 3 months after HGS. As she showed a good performance status, we attempted therapeutic endoscopic intervention via the HGS site; however, intervention was difficult because of the protrusion of the long SEMS ([Fig. 1]). Therefore, stent trimming was performed with APC using an electrosurgical generator (ICC200; ERBE Elektromedizin, Tübingen, Germany) ([Fig. 2 a, b]; [Video 1]). Subsequently, the fragment of SEMS was removed using grasping forceps through the scope channel ([Fig. 2 c]).
Fig. 1 Protrusion into the stomach of the long self-expandable metal stent (SEMS) used for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS): a on computed tomography (CT) scan; b on endoscopy.
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1377388-i850cl1a.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1377388-i850cl1b.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Quality:
![](https://www.thieme-connect.de/media/endoscopy/2014S01/thumbnails/10-1055-s-0034-1377388-i850cl2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Successful bile duct cannulation was achieved using a standard endoscopic retrograde cholangiopancreatography (ERCP) catheter and a 0.025-inch guidewire. The sludge in the bile duct was confirmed on a cholangiogram and was removed with a retrieval balloon catheter ([Fig. 2 d]; [Video 2]). Finally, a 5-Fr straight nasobiliary drainage tube was placed. The procedure was completed without any adverse events. Metal stent trimming using APC may be an effective option for re-intervention after EUS-HGS.
Quality:
Endoscopy_UCTN_Code_TTT_1AR_2AZ
-
References
- 1 Khashab MA, Fujii LL, Baron TH et al. EUS-guided biliary drainage for patients with malignant biliary obstruction with an indwelling duodenal stent (with videos). Gastrointest Endosc 2012; 76: 209-213
- 2 Khashab MA, Valeshabad AK, Leung W et al. Multicenter experience with performance of ERCP in patients with an indwelling duodenal stent. Endoscopy 2014; 46: 252-225
- 3 Ogura T, Masuda D, Imoto A et al. EUS-guided hepaticogastrostomy combined with fine-gauge antegrade stenting: a pilot study. Endoscopy 2014; 46: 416-421
- 4 Ishii K, Itoi T, Sofuni A et al. Endoscopic removal and trimming of distal self-expandable metallic biliary stents. World J Gastroenterol 2011; 17: 2652-2657
- 5 Hamada T, Nakai Y, Isayama H et al. Trimming a covered metal stent during hepaticogastrostomy by using argon plasma coagulation. Gastrointest Endosc 2013; 78: 817