2145 Use of Sypbite Forceps to Successfully Remove a Proximally Migrated Biliary Stent: An Effective Alternative

Abstract

INTRODUCTION: Biliary stents are essential to therapeutic endoscopy. Although being useful in most cases, several complications are reported in literature. One of them is stent migration. We describe the retrieval of a proximally migrated biliary stent into left hepatic duct complicated by a liver abscess using a digital cholangioscope. CASE DESCRIPTION/METHODS: An 83-yrs-old male presented with abdominal pain for 3 days. Denied nausea, vomiting, fever or chills. Patient’s history was significant for pancreatic adenocarcinoma with common bile duct (CBD) stricture diagnosed 1 month prior to this presentation. He underwent ERCP with placement of a 10 F × 9 cm straight plastic stent in the CBD. Post ERCP he did well and was discharged home. A CT scan this admission showed proximal migration of the biliary stent into the left intrahepatic duct along with a fluid-gas collection in the left lobe of the liver. Labs showed leukocytosis, elevated bilirubin and liver enzymes. Patient underwent ERCP for retrieval of the migrated biliary stent. A biliary wire was successfully passed into the left intrahepatic duct. The biliary tree was then swept with three different sizes balloons, but the CBD stent did not move much and remained in the mid duct extending into the LHD. Decision was made to explore the CBD by spyglass. The SpyScope was advanced to the bifurcation. Biliary sludge was found in the entire main bile duct, occluding the stent. Using a spybite forceps the distal end of the stent in the mid duct was grasped and pulled along with the spyscope to the distal most part of the CBD. Major papilla was than dilated and CBD stent was removed using snare. Cholangiography confirmed brisk flow of contrast in entire biliary system. One 10 Fr by 7 cm double pigtail plastic stent was placed 7 cm into the common bile duct to prevent migration. DISCUSSION: Proximal migration of biliary stent in an infrequent occurrence with the reported incidence of 4.9%. Several endoscopic techniques have been described with success rate of 80%. Conventional techniques to retrieve migrated biliary stents includes grasping of the stent with rat-tooth forceps, traction retrieval, wire-guided retrieval basket, and snare. Use of SpyGlass cholangioscopy has been reported rarely for the removal of proximally migrated stent. SpyGlass is an effective way of visualization of the migrated stent and removal at the same time which can be used when conventional techniques fail.