Endoscopic ultrasound-guided rescue of an uncovered self-expanding metallic stent causing biliary obstruction

Removal of a malpositioned uncovered Wallstent (Boston Scientific, Natick, Massachusetts, USA) can be extremely difficult, time-consuming, and associated with the occurrence of complications [1]. Stent extraction using standard polypectomy snare or rat-tooth forceps is often unsuccessful [1]. Alternatively stent removal can be accomplished by piecemeal extraction of individual stent filaments [1] [2] [3] [4]. We present a case in which drainage of the biliary system, obstructed by a Wallstent wedged to the hilum, was achieved by endoscopic ultrasound (EUS)-guided puncture of the left intrahepatic bile duct followed by rendezvous endoscopic retrograde cholangiography (ERC).

A 57-year-old man with metastatic cholangiocarcinoma, who had undergone a previous ERC with placement of an uncovered biliary Wallstent, was referred to us for evaluation of persistent jaundice (bilirubin 58 mg/dl). A repeat ERC showed complete occlusion of the Wallstent, with some contrast spilling into the right biliary system and complete obstruction of the left system (Figure [1 a]).

Figure 1 Fluoroscopic views of the procedure. a Endoscopic ultrasound (EUS)-guided transhepatic contrast injection with a 19-gauge needle (arrow), and the malpositioned uncovered Wallstent with its proximal end wedged into the hilum. b The guide wire was inserted from the left hepatic duct through the stent and into the duodenum. c The Zilver stent was placed through the mesh of the Wallstent.

After multiple unsuccessful attempts at advancing a guide wire through the stent, the duodenoscope was exchanged for a linear-array echo endoscope (Olympus America, Melville, New York, USA), that was used to identify the dilated bile ducts within the left hepatic lobe and to puncture them using a 19-gauge needle. After bile had been aspirated and contrast injected to opacify the biliary system, a 0.035-inch Jagwire (Boston Scientific) was inserted through the needle and advanced antegradely across the mesh of the Wallstent, the hilar stricture, and into the duodenum (Figure [1 b]). A rendezvous ERC was finally performed, with placement of a 6 cm long, 6 mm wide Zilver stent (Wilson-Cook Medical, Winston-Salem, North Carolina, USA) through the meshes of the Wallstent (Figure [1 c]). Serum bilirubin levels were completely normalized 10 weeks after the procedure.

We have reported here an illustrative case of EUS-guided rendezvous biliary drainage; this approach can be considered as a valid alternative to the percutaneous transhepatic route when a malpositioned SEMS, not amenable to endoscopic removal, is the cause of obstruction.

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References

• 1 Kahaleh M, Tokar J, Le T. et al . Removal of self-expandable metallic Wallstents.  Gastrointest Endosc. 2004;  60 640-644
• 2 Ahmed A, Keeffe E B, Imperial J C. A novel technique for endoscopic removal of expandable biliary Wallstent.  Gastrointest Endosc. 1999;  50 279-281
• 3 Egan L J, Baron T H. Endoscopic removal of an embedded biliary Wallstent by piecemeal extraction.  Endoscopy. 2000;  32 492-494
• 4 Levy M J, Wiersema M J. Endoscopic removal of a biliary Wallstent with a suture-cutting device in a patient with primary pancreatic lymphoma.  Endoscopy. 2002;  34 835-837