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DOI: 10.1055/s-0034-1377945
Crisscross anchor-stents to prevent metal stent migration during endoscopic ultrasound-guided hepaticogastrostomy
Corresponding author
Publikationsverlauf
Publikationsdatum:
19. November 2014 (online)
Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has become increasingly utilized to palliate malignant biliary obstruction in patients with inaccessible papillae as a result of duodenal tumor invasion [1] [2]. Although a covered self-expandable metal stent (SEMS) is preferred to a plastic stent in EUS-HGS because of its lower risk of bile leakage [3], SEMS migration can be a fatal complication [4]. Herein, we present a case in which a SEMS at risk of proximal migration was successfully managed by adding plastic stents to serve as an anchor.
An 82-year-old man, who had undergone transpapillary stenting using a covered SEMS for distal bile duct cancer, presented with duodenal obstruction. The biliary SEMS was removed endoscopically, followed by duodenal SEMS placement, and EUS-HGS was performed in segment 3 using a covered SEMS (modified-GIOBOR, width 10 mm, length 10 cm, 1-cm uncovered portion at the proximal end; TaeWoong Medical Inc., Gimpo, Korea). The following day, percutaneous transhepatic biliary drainage was performed for cholangitis in segment 2. During this procedure, there was proximal dislocation of the SEMS as a result of interference between the percutaneous transhepatic biliary drainage catheter and the SEMS. A therapeutic duodenoscope (JF-260V, Olympus, Tokyo, Japan) was inserted immediately, and the distal SEMS end was barely observed ([Fig. 1]). The SEMS was moved 2 cm into the stomach by grasping its distal end using biopsy forceps. Subsequently, we punctured the covered mesh wall of the SEMS using an endoscopic retrograde cholangiopancreatography (ERCP) cannula and a 0.035-inch guidewire ([Fig. 2]), and placed a 5-Fr plastic stent (Geenen, Cook Endoscopy, Winston-Salem, North Carolina, USA). Another plastic stent was placed similarly in a crisscross manner ([Fig. 3]). The patient did not develop any further complications, including cholangitis or SEMS migration.
The management of SEMS migration in EUS-HGS is technically demanding and potentially requires surgical intervention [5]. Crisscrossing anchor stents can be used as a salvage technique to prevent this complication.
Endoscopy_UCTN_Code_TTT_1AS_2AC
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Competing interests: None
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References
- 1 Park do H, Koo JE, Oh J et al. EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study. Am J Gastroenterol 2009; 104: 2168-2174
- 2 Hamada T, Isayama H, Nakai Y et al. Transmural biliary drainage can be an alternative to transpapillary drainage in patients with an indwelling duodenal stent. Dig Dis Sci 2014;
- 3 Kawakubo K, Isayama H, Kato H et al. Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 2014; 21: 328-334
- 4 Kim TH, Kim SH, Oh HJ et al. Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction. World J Gastroenterol 2012; 18: 2526-2532
- 5 Hamada T, Nakai Y, Isayama H et al. Tandem stent placement as a rescue for stent misplacement in endoscopic ultrasonography-guided hepaticogastrostomy. Dig Endosc 2013; 25: 340-341
Corresponding author
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References
- 1 Park do H, Koo JE, Oh J et al. EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study. Am J Gastroenterol 2009; 104: 2168-2174
- 2 Hamada T, Isayama H, Nakai Y et al. Transmural biliary drainage can be an alternative to transpapillary drainage in patients with an indwelling duodenal stent. Dig Dis Sci 2014;
- 3 Kawakubo K, Isayama H, Kato H et al. Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 2014; 21: 328-334
- 4 Kim TH, Kim SH, Oh HJ et al. Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction. World J Gastroenterol 2012; 18: 2526-2532
- 5 Hamada T, Nakai Y, Isayama H et al. Tandem stent placement as a rescue for stent misplacement in endoscopic ultrasonography-guided hepaticogastrostomy. Dig Endosc 2013; 25: 340-341