Post written by Nicholas M. McDonald, MD, from the Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA.
In our video manuscript, we describe a case of recurrent malignant biliary and duodenal obstruction that was caused by tumor ingrowth after prior coaxial biliary and metal stenting.
The tumor ingrowth was treated with argon plasma coagulation (APC) followed by APC of the duodenal stent with settings of 120 W and 1.0 L/min to allow us to melt the interstices of the duodenal stent and permit biliary cannulation through the duodenal stent and into the biliary system, or “jailbreaking,” as we called it.
Finally, a new metal biliary stent was placed through the duodenal stent, allowing for management of the biliary obstruction.
We felt this was a challenging clinical scenario, but one often seen in clinical practice. As chemotherapy and immunotherapy continue to improve, oncology patients live longer and likely will continue to see increases in lifespan.
With any increase in life expectancy, we will also expect a rise in rates of tumor ingrowth of biliary or duodenal stents that were previously placed. Rates of an occluded duodenal and biliary stent are likely to increase in clinical practice, and it is important to have endoscopic techniques available to deal with it.
Uncovered metal stents can be trimmed with APC, particularly in settings where gaining access through the stent is desired. You should start with low APC settings and titrate upwards to achieve the desired effect. In our practice, we rapidly titrate up to settings of 120 W and 1.0 L/min for stent trimming.
Fluoroscopic image of initial tangential biliary stent (yellow arrow) and duodenal stent (red arrow).
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