S2326 Grasping for Straws: A Rare and Challenging Complication of Biliary Stenting

Abstract

INTRODUCTION: Proximal (cephalad) migration of a biliary stent (PMBS) may be associated with severe complications. Prompt recognition and retrieval is important, but may be quite difficult. We present a challenging case of proximal migration of a plastic CBD stent, highlighting techniques used for successful retrieval. CASE DESCRIPTION/METHODS: A 73-year-old F with an indeterminate proximal CBD and common hepatic duct (CHD) stricture undergoing biliary endotherapy presented for a scheduled ERCP. Due to inadequate drainage via retrograde approach, a percutaneous biliary drain (PBD) was placed 9 months ago and patient had undergone multiple biliary drain exchanges and one liver biopsy. Surgical resection was not pursued due to underlying comorbidities. Two weeks prior to presentation, ERCP for internalization of PBD revealed that a previously placed 7Fr x 12cm straight plastic stent had migrated proximally within the anterior RHD (Figure 1). Attempts to retrieve the migrated stent with balloon and snare were unsuccessful, so a 10Fr x 10cm stent was placed and PBD was pulled. On repeat ERCP, direct visualization with Spyglass cholangioscopy revealed the stent to be embedded within the bile duct sidewall at the stricture level (Figure 2). Multiple tools, including balloon catheter, snare and pediatric biopsy forceps failed to remove the stent. Even the cholangioscope biopsy forceps could not grasp stent sufficiently to enable traction and removal. After multiple failed attempts, the stent was successfully retrieved using a small rat tooth forceps via direct grasping of its distal end within the CHD under fluoroscopy. Repeat cholangiogram showed stable findings and no perforation and a 10Fr x 12cm straight plastic stent was replaced. DISCUSSION: PMBS is rare and endoscopic retrieval can be challenging. Risk factors of PMBS include malignant stricture, large stent diameter and shorter stent length. Retrieval of PMBS is critical to avoid complications such as hepatic/ductal perforation and fistula. Endoscopic retrieval methods include Soehendra retriever, basket, lasso technique, balloon and forceps. Cholangioscopy can also be used but was not helpful in this case. Fluoroscopic positioning of rat tooth forceps enabled stent retrieval in our case. We postulate that multiple biliary drain exchanges may have caused proximal migration of the biliary stent. Knowledge of the various tools and techniques to retrieve proximally migrated biliary stents is essential to successfully manage these technically challenging cases.Figure 1.: Fluoroscopic visualization of proximally migrated straight biliary stent appearing as an upside down “V”.Figure 2.: Direct visualization of the embedded distal end of the proximally migrated straight biliary stent using Spyglass cholangioscopy.