2153 Migrated Biliary Stent: When Everything Fails

Abstract

INTRODUCTION: Migrating stents are a well-known complication of biliary stenting, occurring in 5-7% of patients undergoing ERCP. Numerous endoscopic devices are used to remove stents. However, we describe removal of a proximally migrated biliary stent using a cholangioscopy-guided retrieval basket. CASE DESCRIPTION/METHODS: An 86-year-old woman was admitted for septic shock, E. coli bacteremia and cholangitis. Urgent ERCP demonstrated two diverticuli with the major papilla inside one of them. Cholangiogram revealed CBD dilation to 8 mm with few small and large choledocholithiasis. A sphincterotomy and endoscopic dilation of the papilla were performed. However, due to duodenal spasms compromising visualization of the papilla and the associated sepsis, a 10-French by 9 cm plastic stent was placed in the biliary tree and the procedure was aborted. Repeat ERCP four weeks later showed the stent had migrated into the bile duct and was embedded behind the neck of the periampullary diverticulum. Multiple attempts to remove the stent using balloons, baskets, snares and Rat tooth forceps were unsuccessful. A repeat ERCP two weeks later showed the stent still embedded in the bile duct. A Spyglass cholangioscope was introduced into the bile duct and the retrieval basket was used to grasp the distal flap of the stent. Next, both the cholangioscope and stent were successfully withdrawn from the CBD. Finally, the bile duct was swept and remaining stones were removed. Re-inspection of the bile duct with the cholangioscope demonstrated no residual stones or biliary injury. DISCUSSION: Biliary stent migration is a relatively uncommon complication of ERCP. Multiple endoscopic tools have been described to retrieve migrated stents. These include retrieval balloons, baskets, and forceps. The newly developed Spyglass retrieval basket allows direct visualization and removal of the targeted object whether it is a stone or stent. This technique is a nice addition to our armamentarium for clearing the biliary tree. It could potentially lead to decreased radiation exposure and probably to a decrease in the number of procedures. The use of this device to remove migrated stents has not been previously reported. The main difficulty in our case was the suboptimal visualization once the basket was tightened around the stent as this blocks the view of the cholangioscope. Further advances are needed in order to develop devices that are able to close further away from the scope camera preserving cholangioscopic view of the biliary lumen.