Endoscopic transection of distally migrated biliary self-expanding metallic stents by using argon plasma coagulation: a report of 2 cases (with video)

Abstract

Metallic biliary stents have been shown to have higher patency rates and a decreased need for repeat endoscopic intervention than plastic stents in patients with unresectable pancreatic and biliary malignancies. Distal malposition or migration of self-expanding metallic biliary stents occurs rarely but may lead to stent malfunction, mucosal trauma, or ulceration secondary to impaction into the opposite wall of the duodenum. Surgical and percutaneous transhepatic removal of distally migratedmetallic stents has been reportedbut is excessively invasive andcarries apotential for substantial morbidity. While late endoscopic removal of covered stents has been described and is usually feasible, en bloc removal of uncoveredmetallic stents is usually impossible, because they become imbedded in the biliary epithelium; piecemeal extraction of uncovered stents has been reported but is cumbersome and not always possible. Endoscopic transection of metallic stents has been reportedwhen using a neodymium-yttrium aluminum garnet laser, but this technology is not widely available and raises concerns about inadvertent tissue injury and perforation. Argon plasma coagulation (APC) is a widely available method for tissue coagulation. Use of APC to transectmetallic stents has been described from a single institution in Europe but has not been described in the United States. We describe our initial experience when using APC for the transection of distally migrated self-expanding metallic stents.