Plastic stents (PSs) are used in patients with malignant hilar obstruction (MHO),
considering patient life expectancy and reintervention [1]
[2]. Some PSs are designed for suprapapillary stenting and are equipped for thread removal
for reintervention [3]. Here, we present a case that illustrates rare problems caused by the removal of
the thread adhering to the duodenoscope elevator identified using the double-scope
technique [4].
A 65-year-old man with Bismuth type I MHO due to unresectable gallbladder cancer ([Fig. 1]) underwent suprapapillary stenting in a side-by-side fashion using a dedicated PS
(Through & Pass, 7F Inside Stent; Gadelius Medical, Tokyo, Japan) ([Fig. 2]
a, [Fig. 2]
b, [Video 1]). The duodenoscope (TJF-Q290V; Olympus, Tokyo, Japan) was extubated after we washed
the
removing threads out of the scope channel. However, extubation suddenly became disrupted
in the
stomach ([Video 1]). To identify the cause, a second ultra-slim esophagogastroduodenoscope was inserted
along the duodenoscope. We determined that the thread jammed beside the immobile elevator
in the
lifted position ([Fig. 3]
a, [Fig. 3]
b, [Video 1]). Finally, repetitive striking of the lifted elevator with a cannula loosened the
fixed
elevator and released the thread ([Video 1]).
A stent-removing thread sticking adjacent to the duodenoscope elevator identified
using the double-scope technique.Video 1
Fig. 1 Abdominal computed tomography. Computed tomography revealed bilateral dilated intrahepatic
bile ducts caused by gallbladder cancer, which also invaded the right lobe.
Fig. 2 Fluoroscopic image with a duodenoscopic view after inside plastic stent deployment.
a Fluoroscopic image demonstrating double-inside plastic stent indwelling at the hilar
stricture in a side-by-side position. b In the duodenoscopic view, four removal threads of the plastic stents were washed
into the appropriate lumen.
Fig. 3 An ultra-slim endoscope confirms the locked removing thread beside the fixed elevator.
a Fluoroscopic image demonstrating rendezvous of the duodenoscope and ultra-slim scope.
b In the ultra-slim endoscopic view, the thread was visibly locked beside the lifted
and fixed elevator. The solid red arrow indicates an impacted thread. The red dotted
arrow indicates an elevator.
During the release of the stent-removing threads, these threads potentially fall into
the slit between the scope elevator and side wall. If the operator lifts the elevator
in this position, the thread jams tightly in the slit ([Video 1]), which disrupts scope extubation. In this situation, we must avoid pulling the
scope violently; otherwise, the impacted thread tears the papilla and duodenum upward.
This event develops outside the duodenoscope view; therefore, in cases of incomprehensible
disruption of scope extubation, the double-scope technique will clarify the reason.
