Post written by Marc Bernon, MB, ChB, FCS, from the Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa.
Endoscopic placement of self-expanding metal stents (SEMS) is the palliative treatment of choice for obstructive jaundice due to malignant biliary obstruction. However, a particularly challenging scenario exists when inadvertently placed uncovered SEMS for an assumed malignant lesion need removal following subsequent diagnosis of a benign condition. We present a case describing a new technique for removal of embedded uncovered biliary SEMS.
A 58-year-old previously healthy woman presented with obstructive jaundice. Cross-sectional imaging showed a suspected gallbladder cancer with involvement of the common hepatic duct and portal adenopathy. At endoscopic retrograde cholangiography (ERC) the bifurcation was stented with side-by-side 8-cm uncovered SEMS in the right and left hepatic ducts with an additional 6-cm stent placed distally on the left. On review of imaging after referral to our unit 4 weeks later, there was some doubt over the diagnosis and a follow-up MRI was performed showing dramatic regression of the gallbladder mass.
The patient was subsequently taken for ERC for stent removal. Both stents were visible in the duodenum and a standard 420-cm long guidewire was passed through a stent fenestration of the left-sided SEMS. The tip of the guidewire was caught with a polypectomy snare and pulled into the working channel. The endoscope was removed and the sheath of a Soehendra® lithotriptor was advanced over both ends of the doubled guidewire. After connecting the lithotriptor handle, the stent was gently pulled into the sheath by rotating the handle. The stone-crushing device was then removed with the stent inside the metal sheath. This was repeated for the right-sided stent. Minimal bleeding was noted, and two 12-cm 10F plastic stents were placed to ensure patency that could compromise clots and swelling. There were no adverse events, and the patient was discharged the following day.
Endoscopic removal of SEMS can be challenging, especially when attempted more than 2-3 weeks after initial stent placement. The technical complexity of stent extraction increases in situations where inadvertently placed uncovered SEMS for presumed malignant lesions need removal after the subsequent diagnosis of a benign condition. We felt it was important to share this particular video to demonstrate how endoscopic stent removal in this situation is possible and safe when using this newly described technique. Additionally, the method is a cost-effective solution to a difficult problem, as it utilizes a robust multi-use device already available in most ERCP services.
The described technique limits the shear force exerted on the bile ducts by applying force on a limited surface, directly adjacent to the sheath opening and at a 90 degree angle to the biliary wall facilitating stent dislodgement in a step-wise fashion as the sheath moves upward, minimizing trauma. This is opposed to the parallel shearing force exerted on the bile duct over the entire length of the stent by longitudinal extraction with a forceps or snare.
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