Successful removal of an uncovered metallic stent using peroral direct cholangioscopy and the stent-in-stent technique

Long-term biliary stenting can result in complications such as stent migration, fistulas, and stent–stone complexes [1]. We report a case of an uncovered metallic stent exhibiting stent–stone complexes that was successfully removed using peroral direct cholangioscopy (PDCS) and the stent-in-stent technique [2].

An 89-year-old woman was admitted with fever and abdominal pain. Computed tomography revealed a metallic stent placed above the papilla and many stones at the hilar level of the bile duct ([Fig. 1]). Ten years ago, a fully covered self-expandable metallic stent (FCSEMS) was implanted for a choledochoduodenal fistula due to bile duct stones; however, follow-up was interrupted after treatment. We were unable to remove the FCSEMS with rat-tooth forceps because the mesh of the stent was exposed and the inside of the stent was filled with stones. Unable to pass a guidewire through the stent ([Fig. 2]), we performed PDCS (SpyScope DS II; Boston Scientific) with electronic hydraulic lithotripsy to crush the stones within the stent ([Fig. 3]) and create space for devices to pass through the inside [3]. We cleaned the inside of the stent with a balloon catheter (Extractor; Boston Scientific), and then placed an additional FCSEMS (Bonastent; Medico’s Hirata) within the old stent ([Fig. 4]). One month later, we used a snare under fluoroscopic guidance and successfully removed both stents ([Video 1]; [Fig. 5]) [4] [5].

Fig. 1 A metallic stent is seen above the papilla and stones in the hilar bile duct.

Fig. 2 The metallic stent was not removable with rat-tooth forceps and did not allow a guidewire to go through.

Fig. 3 The stones within the stent were crushed using electronic hydraulic lithotripsy.

Fig. 4 A new covered self-expandable metallic stent was placed inside the previously implanted metallic stent.

Video 1 Removal of a longstanding stent (10 years) showing stent–stone complexes. To do this we performed peroral direct cholangioscopy with electronic hydraulic lithotripsy to crush the stones within the stent, followed by insertion of a new fully covered self-expandable metallic stent inside the old stent. One month later, both stents were removed.

Fig. 5 The removed stent had an exposed mesh and was covered with numerous stones.

It has been reported that partially covered and uncovered SEMS can be removed using the stent-in-stent technique with a success rate of approximately 80 % [4]. When placing FCSEMS for benign biliary strictures, prolonged stent implantation should be avoided, and we advise preparation for potential complications.

Endoscopy_UCTN_Code_CPL_1AK_2AI

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kida M, Miyazawa S, Iwai T. et al. Endoscopic management of malignant biliary obstruction by means of covered metallic stents: primary stent placement vs. re-intervention. Endoscopy 2011; 43: 1039-1044
• 2 González N, Ramesh J, Wilcox CM. et al. Endoscopic removal of an impacted bile duct self-expanding metal stent (SEMS) using the SEMS-in-SEMS technique. Endoscopy 2013; 45: E254-E255
• 3 Naveen A, Sandra EN, Gregory BH. et al. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol 2004; 99: 2330-2334
• 4 Mark C, Bryan S, Muhammad J. et al. Complex biliary stones: treatment with removable self-expandable metal stents: a new sapproach (with videos). Gastrointest Endosc 2011; 74: 520-526
• 5 Deepanshu J, Assaf S, Muhammad KH. et al. Stepwise algorithmic approach to endoscopic removal of biliary partially covered and uncovered self-expanding metal stents. Clin Endosc 2021; 54: 608-612

Publication History

Article published online:
03 June 2022