Single Operator Cholangioscopy for Removal of a Proximally Migrated Biliary Stent

Abstract

Biliary stents are used to maintain the patency of the bile duct. Sometimes the stent can migrate proximally requiring specialized interventions for removal. Most migrated stents can be retrieved endoscopically, and a variety of techniques can be used for difficult cases. We used a novel technique of single operator cholangioscopy (SOC) for retrieval of a proximally migrated biliary stent. A 90 year old woman presented to our center for an ERCP for biliary stent removal. Her past history was significant for common bile duct (CBD) stones, which required mechanical and laser lithotripsy. A 10 Fr x 7 cm plastic biliary stent was placed during the index ERCP. During her follow up ERCP, the biliary stent was found to have migrated proximally into the bile duct. Attempts were made to remove the stent using a 2 cm stone retrieval basket, rat-tooth forceps, snare, and biopsy forceps under fluoroscopic guidance, but these were all unsuccessful. The cholangioscope was then inserted into the bile duct and advanced to the level of the distal end of the stent, which appeared to be lodged in the cystic duct takeoff (Fig 1 and 2). Attempts were made to grab the stent and retrieve it with the help of intraductal mini-biopsy forceps but these were unsuccessful (Fig 3). Next, a 0.035” long guidewire was advanced through the distal lumen of the stent into the intrahepatic biliary tree (Fig 4 and 5). The cholangioscope was then exchanged over the guidewire and a 4 mm biliary dilating balloon was advanced into the lumen of the biliary stent (Fig 6). The presence of the balloon within the stent was confirmed with fluoroscopy, and the balloon was partially inflated to 7-8 mm Hg (Fig 7). The balloon and stent were withdrawn together over the wire through the scope channel (Fig 8 and 9). A 12 - 15 mm stone extractor balloon was then advanced into the duct. Occlusion cholangiogram revealed a few tiny filing defects. Balloon sweeps were performed with removal of stone fragments and sludge. There was excellent drainage of contrast and bile post-procedure. No further stenting was required. This video demonstrates the successful use of single-operator cholangioscopy directed guidewire placement followed by a biliary dilating balloon for retrieval of a proximally migrated biliary stent when conventional retrieval methods have failed. Watch the video: https://goo.gl/4FJvFD