Endoscopic Management of Duodenal Obstruction Due to Migrated Biliary Stents

Abstract

Distal migration of self-expandable metal stents (SEMS) from the bile duct could potentially result in ulceration, bleeding and duodenal obstruction. We describe endoscopic management of two patients with duodenal obstruction from migrated SEMS. Endoscopic argon plasma coagulation (APC) and cap-assisted stent fracture techniques were used to recanalize the lumen. Case 1: A 64 year-old Hispanic male with unresectable pancreatic head carcinoma presented with obstructive jaundice and ascites. Two overlapping SEMS biliary stents and an internal-external drain was placed. Subsequently, the patient developed symptomatic duodenal obstruction as confirmed by Upper GI series (see figure).FigureEndoscopic transection of the migrated segment of the stent with APC was unsuccessful due to the narrow lumen. Using cap assisted endoscopy, the distal end of the stent was brought in the bulb by using an endoloop. The migrated segment of the stent was fractured against the cap of the endoscope by grasping and pulling pieces of the stent with a Pelican forceps, until the stent segment in the lumen was completely cleared. Barium study 2 days later showed a patent C-loop of duodenum, with excellent flow. Patient tolerated oral diet and was discharged from the hospital 24 hrs later. Case 2: A 66 yr-old male with unresectable ampullary cancer treated with SEMS presented with obstructive jaundice and UGI bleeding. Endoscopy revealed a migrated biliary stent impinging against the posterior wall of the duodenum causing ulceration, bleeding and gastric stasis. Endoscopic retrieval of the stent resulted in hemorrhage, which was controlled by embolization of the gastro-duodenal artery. Subsequently, endoscopic transection of the distally migrated segment with APC was performed along with retrieval of the stent wires in piecemeal fashion with a grasping forceps. Patient was able to resume oral diet and was discharged from the hospital 24 hrs later. We conclude that endoscopic removal of migrated biliary stent can be performed safely. [figure 1]