Post written by Arjun Chatterjee, MD, from the Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
A 56-year-old man presented with painless jaundice. A CT scan reported a pancreatic mass, and he underwent ERCP at an outside facility with the placement of a plastic biliary stent through distal biliary stricture and EUS-guided biopsy of the pancreatic mass, which confirmed pancreatic ductal adenocarcinoma.
A follow-up CT of the chest/abdomen revealed a significant proximal migration of the pre-existing plastic biliary stent. This was abutting the liver margin of the left hepatic lobe, and the distal end was above the malignant biliary strictures in the area of the hepatic hilum. Repeat ERCP confirmed the proximally migrated biliary stent seated above 2 separate strictures in the common hepatic and distal common bile duct.
To retrieve the stent, we considered using fluoroscopy-guided grasping devices, snare, extraction, and dilation balloons. But all these could have led to further migration of the stent, resulting in liver capsule injury.
Therefore, mini-forceps were used to successfully grasp the stent under direct cholangioscopic view.
The main goal of presenting this video is to highlight the cognitive aspect of ERCP apart from the technical competence. Several tools and techniques were available and considered.
Neither placing a new biliary stent distally nor attempting fluoroscopy-guided removal of the migrated stent with the usual maneuvers (extraction balloon or basket, biopsy forceps, snare, or dilating balloon in or alongside the migrated stent) would have resulted in favorable outcomes. Cholangioscopy-guided cannulation and advancement of extraction/dilating balloon and inflation within the stent to attempt extraction of the migrated stent also were considered.
All these strategies could have resulted in further proximal stent migration and liver capsule injury. Advancement of non–wire-guided biopsy forceps under fluoroscopic guidance for stent retrieval could not be performed because of the high-grade nature of distal strictures, risking duct injury. The safest maneuver was the dilation of biliary strictures before wire-guided cholangioscopy for direct visualization of the stent and retrieval with mini-forceps, as demonstrated in the video.
Although several tools and techniques are available for the retrieval of migrated biliary stents, the application of cognitive competence is equally crucial in the successful and safe outcome of ERCP.
ERCP image showing proximally migrated common bile duct stent and introduction of cholangioscope.
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