Open-biopsy-forceps technique for removing biliary metallic stents that have migrated distally and wedged transversely in the duodenum

We read with interest the article by Shin et al. [1] on a prospective study of the endoscopic removal of malfunctioning biliary metallic stents. All attempts at stent removal were made using a therapeutic duodenoscope and a rat-tooth forceps. They removed covered stents easily in 19/22 patients, but were unable to remove any of the eight uncovered stents. Although they successfully removed all the stents that had migrated distally (three covered stents), they did not encounter any stents that had migrated distally and wedged transversely in the duodenum. In such a situation, the distal end of the stent becomes impacted in the duodenal wall opposite the papilla, and endoscopic removal of such stents is extremely difficult [2]. If endoscopic removal of the impacted stent fails, it might have to be removed surgically.

Self-expandable metallic stents have been widely used for the palliation of inoperable malignant biliary obstruction [3] [4] [5]. Although metallic stents have improved stent patency in comparison with plastic stents because of their larger luminal diameter [3] [4] [5], tumor ingrowth through the wire mesh, which leads to stent occlusion, and the inability to remove the stent remain drawbacks of this type of stent. Covered metallic stents were designed to prevent tumor ingrowth, but these stents often migrate [2] [3] [5], although removal of covered stents is more successful than removal of uncovered stents because they penetrate less deeply into the biliary wall than uncovered stents [5].

In cases of partial stent migration into the duodenum, covered metallic stents can be removed by capturing the free distal end with a polypectomy snare [3] [4] [6] or a rat-tooth forceps [1] [6]. Occasionally the stents become wedged transversely in the duodenum and the distal end of the stent is impacted in the duodenal wall opposite the papilla, which makes it impossible to grasp [3]. However, these stents can be removed by forming a tight loop around the impacted stent with a snare and a guide wire [5] or a silk tie grasped by a biopsy forceps [7], and they can then be withdrawn through the duodenoscope. Trimming of such stents with argon plasma coagulation [3] [8] or laser [9] is an alternative approach. However, all these endoscopic removal or trimming techniques for removing impacted stents are time-consuming, and require the use of a therapeutic duodenoscope [5] [10].

We have previously reported successfully using an open-biopsy-forceps technique with a standard front-viewing endoscope for removing metallic stents that have migrated distally and impacted in the duodenal wall [5]. The technique was used in four patients. A closed biopsy forceps was first advanced through the stent mesh, and opened within the stent, forming an “anchor” inside the stent. The stent was easily dislodged from the duodenum to the stomach as the endoscope was withdrawn. After snaring of the stent end, the stent was removed by complete endoscope withdrawal. The technique itself took a mean time of 10.2 minutes to perform.

The open-biopsy-forceps technique is a simple, rapid, and effective method for the endoscopic removal of distally migrated and impacted metallic stents that requires no special equipment. In the era of endoscopic biliary stenting, covered metallic stents are being increasingly widely used in patients with inoperable malignant biliary obstruction, which means that there is an increased likelihood of stent migration. Biliary endoscopists should consider using this technique before embarking on surgical stent removal when this challenging situation arises.

References

• 1 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
• 2 Matsushita M, Takakuwa H, Nishio A. et al . Open-biopsy-forceps technique for endoscopic removal of distally migrated and impacted biliary metallic stents.  Gastrointest Endosc. 2003;  58 924-927
• 3 Kahaleh M, Tokar J, Le T. et al . Removal of self-expandable metallic Wallstents.  Gastrointest Endosc. 2004;  60 640-644
• 4 Wamsteker E J, Elta G H. Migration of covered biliary self-expanding metallic stents in two patients with malignant biliary obstruction.  Gastrointest Endosc. 2003;  58 792-793
• 5 Itoi T, Nakamura K, Sofuni A. et al . Endoscopic removal of a dislocated covered Wallstent using a wire-loop technique.  Dig Endosc. 2003;  15 311-314
• 6 Familiari P, Bulajic M, Mutignani M. et al . Endoscopic removal of malfunctioning biliary self-expandable metallic stents.  Gastrointest Endosc. 2005;  62 903-910
• 7 Matsushita M, Takakuwa H, Nishio A. A low-cost removal technique and clip closure for distally migrated and embedded biliary stents.  Gastrointest Endosc. 2001;  53 841-842
• 8 Guda N M, Freeman M L. Endoscopic transection of distally migrated biliary self-expanding metallic stents by using argon plasma coagulation: a report of 2 cases.  Gastrointest Endosc. 2006;  63 512-514
• 9 Shaver C P, Brady P, Pinkas H. You don’t have to retrieve to relieve: how and when to trim a self-expanding metal biliary stent.  Endoscopy. 2004;  36 833
• 10 Matsushita M, Takakuwa H, Matsubayashi Y. et al . Distally migrated and impacted biliary metallic stents: removal versus trimming.  Endoscopy. 2005;  37 677