Hemorrhage after laser-cut covered self-expandable metal stent removal

Endoscopic covered self-expandable metal stent (CSEMS) placement is widely used for distal malignant biliary obstruction (MBO) as the stent prevents ingrowth and is easily removed [1] [2]. The usefulness of the laser-cut CSEMS (LC-CSEMS) and its endoscopic removal have been reported [3] [4] [5]; there have been no previous reports of complications related to LC-CSEMS removal. We here report a case of hemorrhage following LC-CSEMS removal.

An 83-year-old woman was referred for cholangitis. She had undergone endoscopic LC-CSEMS (X-Suit NIR covered biliary metal stent; Olympus Medical Systems, Tokyo, Japan) placement 7 months previously for unresectable pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP) was performed because recurrent biliary obstruction was suspected ([Fig. 1]; [Video 1]). Cholangiography revealed defects suggestive of sludge ([Fig. 2]). We therefore decided to remove the LC-CSEMS and replace it with a new one.

Fig. 1 Endoscopic retrograde cholangiopancreatography findings showing: a the endoscopic appearance of the successfully placed laser-cut covered self-expandable metal stent (LC-CSEMS) for a patient with unresectable pancreatic cancer; b the fluoroscopic appearance of the successfully placed LC-CSEMS.

Video 1 Difficult removal of a laser-cut covered self-expandable metal stent (LC-CSEMS) causing hemorrhage from the papilla that was subsequently controlled by insertion of a replacement LC-CSEMS.

Fig. 2 Cholangiographic appearance with defects (pink arrows) suggestive of sludge.

A snare forceps was used to hold the LC-CSEMS, which was moved toward the papilla by pushing, along with clockwise torsion of the endoscope while adjusting the axis of the bile duct [3]. The initial attempt to pull the LC-CSEMS out was effective; however, the snare subsequently could not be released, with the plan having originally been to release it from the LC-CSEMS and reposition it nearer the papilla ([Fig. 3 a]). Consequently, the LC-CSEMS was instead removed by withdrawing the endoscope.

Fig. 3 Endoscopic views showing: a the snare forceps, which could not be released, holding the partially withdrawn laser-cut covered self-expandable metal stent; b hemorrhage that was induced during laser-cut covered self-expandable metal stent removal.

After stent removal, we inserted the endoscope to the papilla and found that a hemorrhage had been induced from the papilla during LC-CSEMS removal ([Fig. 3 b]). Although biliary cannulation was possible, the hemorrhage disturbed the endoscopic view, so re-insertion of the new LC-CSEMS was performed under fluoroscopic guidance. The LC-CSEMS suffers from minimal stent shortening because of the laser-cut structure; therefore, it could be placed easily in an accurate position ([Fig. 4 a]) and the hemorrhage was finally stopped by compression from the LC-CSEMS ([Fig. 4 b]). Although this hemorrhage was induced by LC-CSEMS removal, it was easily stopped after the LC-CSEMS was replaced.

Fig. 4 Endoscopic retrograde cholangiopancreatography findings showing: a the fluoroscopic appearance of the successfully placed accurately positioned laser-cut covered self-expandable metal stent (LC-CSEMS); b the endoscopic appearance with hemostasis successfully achieved by compression from the LC-CSEMS.

Endoscopy_UCTN_Code_CPL_1AK_2AD

Competing interests

The authors declare that they have no conflict of interest.

Acknowledgments

We would like to thank Editage (www.editage.com) for English language editing.

• References

• 1 Isayama H, Komatsu Y, Tsujino T. et al. A prospective randomised study of “covered” versus “uncovered” diamond stents for the management of distal malignant biliary obstruction. Gut 2004; 53: 729-734
• 2 Kitano M, Yamashita Y, Tanaka K. et al. Covered self-expandable metal stents with an anti-migration system improve patency duration without increased complications compared with uncovered stents for distal biliary obstruction caused by pancreatic carcinoma: a randomized multicenter trial. Am J Gastroenterol 2013; 108: 1713-1722
• 3 Tanisaka Y, Ryozawa S, Kobayashi M. et al. Endoscopic removal of laser-cut covered self-expandable metallic biliary stents: A report of six cases. Mol Clin Oncol 2018; 8: 269-273
• 4 Marui S, Uza N, Yamazaki H. et al. Utility of laser-cut covered self-expandable metal stents for unresectable malignant distal biliary obstruction: a single-center experience. Endoscopy 2020; 52: 664-668
• 5 Kin T, Ishii K, Okabe Y. et al. Feasibility of biliary stenting to distal malignant biliary obstruction using a novel designed metal stent with duckbill-shaped anti-reflux valve. Dig Endosc 2021; 33: 648-655

Publication History

Article published online:
09 August 2021