Endoscopy 2014; 46(S 01): E563
DOI: 10.1055/s-0034-1377945
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Crisscross anchor-stents to prevent metal stent migration during endoscopic ultrasound-guided hepaticogastrostomy

Yusuke Shima
1   Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
2   Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Hiroyuki Isayama
1   Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
2   Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Yukiko Ito
1   Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
,
Tsuyoshi Hamada
2   Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Yousuke Nakai
2   Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Takeshi Tsujino
1   Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
,
Ryo Nakata
1   Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
,
Kazuhiko Koike
2   Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Corresponding author

Hiroyuki Isayama, MD, PhD
Department of Gastroenterology
Graduate School of Medicine
The University of Tokyo
7-3-1 Hongo, Bunkyo-ku
Tokyo 113-8655, Japan
Fax: +81-3-38140021   

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.

Zoom Image
Fig. 1 A covered self-expandable metal stent (SEMS) used for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) had nearly migrated into the peritoneal cavity of an 82-year-old man as a result of interference between the percutaneous transhepatic biliary drainage catheter and the SEMS. The distal end of the stent could barely be seen.
Zoom Image
Fig. 2 An endoscopic retrograde cholangiopancreatography (ERCP) cannula was used to puncture the mesh wall of the covered self-expandable metal stent (SEMS). A guidewire was then passed through the mesh wall and the opposite wall of the metal stent.
Zoom Image
Fig. 3 The crisscrossing anchor stents technique was used to prevent proximal migration of the metal stent. Two crisscrossed 5-Fr plastic stents served as an anchor to prevent stent 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

  • 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

Hiroyuki Isayama, MD, PhD
Department of Gastroenterology
Graduate School of Medicine
The University of Tokyo
7-3-1 Hongo, Bunkyo-ku
Tokyo 113-8655, Japan
Fax: +81-3-38140021   

  • 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

Zoom Image
Fig. 1 A covered self-expandable metal stent (SEMS) used for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) had nearly migrated into the peritoneal cavity of an 82-year-old man as a result of interference between the percutaneous transhepatic biliary drainage catheter and the SEMS. The distal end of the stent could barely be seen.
Zoom Image
Fig. 2 An endoscopic retrograde cholangiopancreatography (ERCP) cannula was used to puncture the mesh wall of the covered self-expandable metal stent (SEMS). A guidewire was then passed through the mesh wall and the opposite wall of the metal stent.
Zoom Image
Fig. 3 The crisscrossing anchor stents technique was used to prevent proximal migration of the metal stent. Two crisscrossed 5-Fr plastic stents served as an anchor to prevent stent migration.