Post written by Mayu Nishiyama, MD, Shigeto Ishii, MD, Toshio Fujisawa, MD, PhD, Hiroaki Saito, MD, PhD, and Hiroyuki Isayama, MD, PhD, from the Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.

This is a case of unresectable hilar cholangiocarcinoma in a 74-year-old man. He developed acute cholecystitis after biliary stent placement and received EUS-guided gallbladder drainage with a 7 Fr, 15-cm double-pigtail stent and naso-gallbladder catheter. However, biliary peritonitis developed due to double-pigtail stent migration into the peritoneal cavity. Percutaneous peritoneal and gallbladder drainage was ineffective because of continuous leakage of bile juice. Therefore, we decided to endoscopically remove the migrated stent. Alligator forceps were inserted into the peritoneal cavity, along the pre-placed guidewire through the fistula, and gradually advanced toward the stent under fluoroscopic guidance. Finally, the migrated stent was tightly grasped and pulled out through the fistula without any adverse events.

Stent migration in interventional EUS procedures is one of most severe adverse events because most cases require emergency surgery. Endoscopic removal using alligator forceps was considered a promising salvage technique to remove migrated stents in abdominal cavity. The migrated stent was located beside the puncture hole as expected. We could then approach under fluoroscopic guidance. If the was stent located apart from the fistula, we could not encounter the stent in the peritoneal cavity. In addition, drainage of peritoneal cavity was mandatory to improve the peritonitis.

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