Post written by Brian S. Lim, MD, MCR, FASGE, from the School of Medicine, University of California, and the Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, California, USA.

A 60-year-old male presented with right lower-quadrant pain and fever. CT (computed tomography) abdomen showed acute appendicitis, but also an incidental biliary stent. The atient had ERCP 6 years prior but never followed up for stent removal. ERCP showed a proximally migrated biliary stent. Stent extraction was attempted by pulling an extraction balloon alongside the stent but met resistance at the ampulla. After sphincteroplasty, further attempt at removal with extraction balloon and various other instruments was unsuccessful. The stent was cannulated with a guidewire; we attempted to extract it by bowing the papillotome inside stent lumen without success. A screw-type stent extractor was inserted over the wire into the distal end of the stent. Although the distal end was pulled into the duodenum, it eventually broke off. An attempt at extraction with a snare resulted in the stent breaking off multiple times. Cholangiogram showed a large filling defect surrounding the stent in CBD, and it was determined that the stent was embedded or ‘fossilized’ in this stone that likely formed around the stent over the years. After adequate laser lithotripsy of the stone around the stent and removal of numerous stone fragments, the remainder of the stent was successfully extracted out of the bile duct using a metal basket. Occlusion cholangiogram and repeat cholangioscopy confirmed complete removal of the stone.

Stent migration occurs in 5-10% of patients undergoing biliary stenting. Therefore, it is important to be prepared to employ various retrieval techniques. We encountered a unique situation in which the proximally migrated biliary stent resulted in a difficult extraction due to stone formation around the stent, sometimes referred to as a ‘lollipop stone.’ We felt that it was important to showcase this particular video because laser lithotripsy in conjunction with retrieval of migrated biliary stent is an interesting clinical scenario that has not been reported.

By watching this video, biliary endoscopists can review the details of 3 major categories of proximal stent migration management: (1) via direct traction, (2) through indirect traction, (3) cannulation of the duct/stent lumen with a guidewire then using various over-the-wire accessories. When endoscopists encounter a challenging situation in which pulling the distal end of the stent into the duodenal lumen is accomplished but complete extraction is not achievable (breaking off into multiple pieces in our case), they need to consider ‘lollipop stone’ as a possibility.

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