Plastic biliary stent trimming using endoscopic scissors. These are our disclosures. Our case begins with a 62-year-old woman with unresectable gallbladder cancer on palliative chemotherapy. She had known complex biliary stenosis involving the bifurcation and left primary insertion. Her bilirubin was 4.0, which was up from 0.6 just one month prior. Two months ago, she had undergone ERCP with plastic stenting of the left and right intrapadics and returned for stent exchange. Here we can see a fluoroscopic image from her previous ERCP showing a complex biliary stenosis. An ERCP was performed for stent exchange and the two prior plastic stents appeared occluded. After stent removal, the bile duct was cannulated. The complex malignant-appearing stenosis of the bifurcation, common hepatic, and left primary were again seen. After balloon sweep, an 8.5 French by 20 centimeter plastic stent was placed into the left intrapadic and an 8.5 French by 17 centimeter plastic stent was placed into the right intrapadic. Then using endoscopic scissors, the distal end of the stent was trimmed to minimize contact with the duodenal wall. Here you can see a plastic biliary stent which is too long and the back end is in contact with the duodenal wall, theoretically increasing risks of perforation and migration. This can also decrease the stent's ability to drain and increase the risk of occlusion. An endoscopic scissors is used to make an initial cut at the side hole. A second cut is made to complete the trimming. The remaining portion of the stent was retrieved via cold snare. Here is a final endoscopic view after the stent was trimmed to fit. Of note, the stents that we used here were designed to be trimmed ex vivo, though estimating the exact length can be difficult and the ability to trim in vivo allows one to err on the side of too long with subsequent trimming. Plastic biliary stents can be challenging to size, particularly when multiple stents are placed and they can drive each other inwards. If a stent is too short, it may not be long enough to achieve adequate drainage. However, if a stent is too long, it may press against the duodenal wall, increasing risk of perforation or migration. If you do choose a stent which is too long, removing the stent and recannulating takes extra time and the cost of a new stent. In this scenario, stent trimming can be safely and effectively performed to prevent this. Choosing the correct stent length is important, as problems can arise with stents that are too long or too short. When faced with a plastic biliary stent which is too long, stent trimming is safe and effective for achieving the desired length and may reduce procedural time and cost.

trimming

plastic biliary stent

endoscopic scissors

gallbladder cancer

stent exchange