A 77-year-old woman with advanced pancreatic cancer presented with combined biliary
and duodenal malignant obstruction. An uncovered self-expandable metal stent (SEMS)
(Nexent Duodenal/Pyloric stent, 22 mm × 12 cm; Next Biomedical, Korea) and a partially
covered SEMS (Niti-S ComVi stent, 20 mm × 12 cm; Century Medical, Korea) were deployed
for the duodenal obstruction ([Fig. 1]). After three cycles of chemotherapy, the two duodenal SEMSs had migrated to the
transverse colon ([Fig. 2]). We decided to remove the SEMSs to avoid perforation. A short-type single-balloon
enteroscope (SIF-H290S; Olympus Medical, Japan) was inserted with the overtube ([Video 1]). The SEMSs were identified at the bending part of the colon. We first tried to
grasp the distal end with a rat-tooth forceps, but the SEMSs were tightly embedded
in the wall. Therefore, the enteroscope was inserted across the SEMSs and the proximal
end of the partially covered SEMS was grasped by the forceps and removed using the
invagination method. The SEMSs and the enteroscope were pulled into the overtube so
as not to injure the intestinal wall. Both SEMSs were successfully removed without
any complications ([Fig. 3, ]
[Fig. 4, ]
[Fig. 5]; [Video 1]).
Fig. 1 Stent placement to treat malignant duodenal obstruction. A partially covered duodenal
stent was deployed as a second stent due to tumor ingrowth into an uncovered duodenal
stent.
Fig. 2 Computed tomography revealed that the two duodenal stents had migrated into the colon.
Video 1 Endoscopic removal of two duodenal stents that had migrated into the colon, using
the invagination method.
Fig. 3 Colonoscopic view just after stent removal.
Fig. 4 Endoscopic view of duodenum where the duodenal stents were previously placed.
Fig. 5 Colonoscopic view 1 week after stent removal.
Several methods have been reported for removal of migrated enteral SEMSs [1]
[2]
[3]
[4]. Most of these techniques are quite difficult when the distal end is located at
the bending part of the colon. The invagination method has been reported to facilitate
removal of an embedded biliary SEMS [5]. With this method, the proximal end of the SEMS is grasped with forceps and the
SEMS removed by pulling it inside itself. This method could be useful when it is difficult
to remove a SEMS from the distal end. It is important to lessen the risk of perforation
by advancing the overtube near the SEMS, pulling the enteroscope and the SEMS into
the overtube, and gradually, little by little, detaching the SEMS from the intestinal
wall.
Endoscopy_UCTN_Code_CPL_1AI_2AD
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