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DOI: 10.1055/s-0030-1255792
© Georg Thieme Verlag KG Stuttgart · New York
Application of the “covered-stent-in-uncovered-stent” technique for easy and safe removal of embedded biliary uncovered SEMS with tissue ingrowth
P. H. DeprezMD, PhD
Gastroenterology
Cliniques Universitaires Saint-Luc
Université Catholique de Louvain
Av. Hippocrate 10
1200 Brussels
Belgium
Fax: +32-2-7648927
Email: pdeprez@uclouvain.be
Publication History
Publication Date:
26 November 2010 (online)
Removal of embedded biliary uncovered self-expandable metal stents (uSEMS) is regarded as difficult or even impossible when the duration of indwell exceeds a couple of weeks, because of the ingrowth of tissue [1] [2] [3]. The presence of diffuse and severe ingrowth is the main feature limiting SEMS removal [1]. In the esophagus, placement of a self-expanding plastic stent (SEPS) inside the SEMS has been shown to induce pressure necrosis of this tissue hyperplasia, allowing subsequent removal of the stent [4]. We applied this technique in a 58-year-old patient with a history of alcohol abuse, obstructive jaundice, and suspected malignancy, in whom an uSEMS 10 mm wide and 6 cm long (Wallflex; Boston Scientific, Natick, Massachusetts, USA) had been mistakenly inserted more than 1 year before. The patient had experienced recurrent cholangitis due to stent obstruction caused by tissue ingrowth. Stent removal was therefore considered, but was unsuccessful using conventional maneuvers. A covered SEMS (Wallflex) was then placed inside the uSEMS ([Figs. 1], [2]).
The patient developed acute cholecystitis and a liver abscess, needing percutaneous drainage and prolonged antibiotherapy. Four weeks later, after resolution of the sepsis, removal of both stents was reattempted but failed due to persistent tissue ingrowth. A new covered SEMS was inserted for another 4-week period. Endoscopic retrograde cholangiopancreatography showed spontaneous migration of the covered stent and disappearance of the tissue hyperplasia, except at the distal end of the metal stent ([Fig. 3]).
Removal of the uncovered stent was, however, easy using a rat-tooth forceps ([Fig. 4]).
Damage to the bile duct was checked using SpyGlass (Boston Scientific), which showed permeability and no residual stricture ([Fig. 5]).
Removal of biliary uncovered SEMS is less successful than removal of covered stents (0 – 38 % vs. 92 %). We previously reported on piecemeal extraction of double uncovered Wallstents in a laborious procedure [5]. More recently we applied the “covered-stent-in-uncovered-stent” technique described for removal of esophageal SEMS in the biliary tree and showed that a period of 6 – 8 weeks might be appropriate for successful and less time-consuming removal.
Competing interests: None
Endoscopy_UCTN_Code_TTT_1AR_2AZ
#References
- 1 Familiari P, Bulajic M, Mutignani M. et al . Endoscopic removal of malfunctioning biliary self-expandable metallic stents. Gastrointest Endosc. 2005; 62 903-910
- 2 Stainier L, Hubert C, Jouret M. et al . Self-expanding metallic stents in benign postoperative biliary strictures: a difficult surgical obstacle?. Hepatogastroenterology. 2007; 54 999-1003
- 3 Shin H P, Kim M H, Jung S W. et al . Endoscopic removal of biliary self-expandable metallic stents: a prospective study. Endoscopy. 2006; 38 1250-1255
- 4 Eisendrath P, Cremer M, Himpens J. et al . Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy. 2007; 39 625-630
- 5 Lahlal M, Gigot J F, Annet L, Deprez P H. Successful endoscopic extraction of a double uncovered expandable metal stent. Endoscopy. 2009; 41 Suppl 2 E98-E99
P. H. DeprezMD, PhD
Gastroenterology
Cliniques Universitaires Saint-Luc
Université Catholique de Louvain
Av. Hippocrate 10
1200 Brussels
Belgium
Fax: +32-2-7648927
Email: pdeprez@uclouvain.be
References
- 1 Familiari P, Bulajic M, Mutignani M. et al . Endoscopic removal of malfunctioning biliary self-expandable metallic stents. Gastrointest Endosc. 2005; 62 903-910
- 2 Stainier L, Hubert C, Jouret M. et al . Self-expanding metallic stents in benign postoperative biliary strictures: a difficult surgical obstacle?. Hepatogastroenterology. 2007; 54 999-1003
- 3 Shin H P, Kim M H, Jung S W. et al . Endoscopic removal of biliary self-expandable metallic stents: a prospective study. Endoscopy. 2006; 38 1250-1255
- 4 Eisendrath P, Cremer M, Himpens J. et al . Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy. 2007; 39 625-630
- 5 Lahlal M, Gigot J F, Annet L, Deprez P H. Successful endoscopic extraction of a double uncovered expandable metal stent. Endoscopy. 2009; 41 Suppl 2 E98-E99
P. H. DeprezMD, PhD
Gastroenterology
Cliniques Universitaires Saint-Luc
Université Catholique de Louvain
Av. Hippocrate 10
1200 Brussels
Belgium
Fax: +32-2-7648927
Email: pdeprez@uclouvain.be