Endoscopic retrieval of approximately migrated biliary stent using ESWAL, EHL, and cholangioscopy with Mini-SNARE. Co-authors include Vladimir Kushner, Dr. Weaver, and Dr. Kushner have no financial disclosures and no relevant relationships with industry. Plastic biliary stents are commonly used for a variety of malignant and benign biliary disorders. Stent migration occurs in 5 to 10% of patients. Approximately migrated biliary stents are rare and can result in abdominal pain, biliary obstruction, or injury to the bile duct wall. Society guidelines recommend removal or replacement of plastic biliary stents after 3 to 6 months in order to decrease the risk of stent-related complications. A retained or forgotten stent can lead to stent migration, stent occlusion, cholangitis, perforation, or stentolith formation. This is a case of a 69-year-old female with a history of choledocal lithiasis who underwent ERCP in 2014 with removal of stones and placement of a plastic biliary stent. She was subsequently lost to follow-up without stent removal. She presented to an outside hospital 6 years later with right upper quadrant pain and fevers, and a CT demonstrated intra-hepatic and extra-hepatic biliary ductal dilation, choledocal lithiasis, and a common bile duct stent that had migrated approximately. An ERCP was performed at the outside hospital, and the previously placed biliary stent was not endoscopically visible at the major papilla and had migrated approximately. Attempts were made to remove the stent during ERCP with traction retrieval using a biliary balloon and a lithotripsy basket, though this was unsuccessful. Balloon sweeps were performed with removal of multiple stones. A 10 French stent was placed, and the patient was referred to a tertiary care center for repeat ERCP and attempted removal of the approximately migrated stent. An ERCP was performed, and a cholangiogram demonstrated multiple filling defects consistent with choledocal lithiasis surrounding the previously placed approximately migrated biliary stent. Cholangioscopy was notable for a large amount of stone material obstructing and surrounding the previously placed stent. Cholangioscopy directed electrohydraulic lithotripsy, EHL, was performed. However, complete stone fragmentation was unsuccessful during the first ERCP. Repeat ERCP three weeks later with successful stone fragmentation using a combination of extracorporeal shockwave lithotripsy, ESWAL, and EHL, followed by stent removal using a mini snare. Complete stone removal and duct clearance was completed with mechanical lithotripsy and balloon sweeps. An ERCP was performed, and initial fluoroscopic images demonstrated approximately migrated common bile duct stent. A cholangiogram was obtained that demonstrated multiple filling defects consistent with choledocal lithiasis surrounding the previously placed biliary stent. As conventional removal of the biliary stent was not going to be possible, the bile duct was explored endoscopically using cholangioscopy. Upon entry, a large amount of stone material was appreciated, completely occluding the previously placed stent and nearly surrounding the proximal and distal ends of the biliary stent. Subsequently, cholangioscopy-directed electrohydraulic lithotripsy was performed for stone fragmentation. This was performed in a distal to proximal fashion in order to loosen the stent from the densely adherent stone material. Extensive lithotripsy was performed. However, complete stone fragmentation was unsuccessful due to multiple lithotripsy probes breaking. Subsequent balloon sweeps were performed with incomplete removal of the biliary stones. Two temporary 10 French plastic stents were placed, and repeat ERCP with ESWAL and cholangioscopy was scheduled in two to four weeks for stone and stent removal. The patient returned three weeks after initial ERCP for ESWAL and repeat ERCP for attempted stent extraction. A nasal biliary tube was passed into the biliary tree in order to facilitate ESWAL. ESWAL was performed with 5,000 shockwaves delivered, and repeat ERCP was subsequently performed. Subsequent ERCP re-demonstrated the retained biliary stent, and cholangiogram revealed multiple filling defects consistent with stones. Balloon sweeps were performed with removal of multiple stones. Repeat cholangioscopy revealed a plastic stent that remained completely surrounded by stones and stone debris. Cholangioscopy-directed electrohydraulic lithotripsy was successfully performed in order to fragment the extensive stone material around the stent. Under fluoroscopic and cholangioscopic guidance, a mini-snare was used to grasp the distal flange of the previously placed biliary stent. The stent was subsequently removed from the biliary tree. Following stent removal, there remained significant stone burden in the bile duct. Repeated balloon sweeps were performed with removal of many large stones. However, several large stones remained. Subsequently, mechanical lithotripsy was performed in order to fragment the remaining large stones. Multiple repeated balloon sweeps were performed with removal of many small and large stones, resulting in clearance of the bile duct. In these endoscopic images, one can see the extensive stone burden that was removed from the bile duct. ERCP, in combination with ESWAL, cholangioscopy-directed electrohydraulic lithotripsy, mechanical lithotripsy, and mini-snare can be used to retrieve approximately migrated retained biliary stent with stone impaction. Care should be taken to ensure timely removal of biliary stents in order to prevent stent retention.

biliary stent

migrated stent

choledocal lithiasis

ERCP

stone removal