Endoscopic retrieval of proximally migrated biliary stents by single-operator cholangioscopy. A rare complication of ERCP is common bile duct stent migration. Stent migration occurs in 1.7 to 10% of cases and is associated with an array of adverse events. There are no definitive societal recommendations for removal of proximally migrated biliary stents. Various techniques with accessory tools such as extraction balloon and forceps are routinely used for stent retrieval with variable success. The potential complications associated with these fluoroscopy-guided techniques include bile duct injury, bleeding, and perforation. We present two cases of biliary stent migration into the left intrahepatic duct with successful retrieval of the stents by single-operator cholangioscopy. Case 1. A 90-year-old man with a history of GERD, complicated by severe esophageal stenosis, presented with a urinary tract infection and incidentally found to have significantly dilated CBD with choledocolithiasis on CT scan. The patient had a cholecystectomy in the past. EGD was initially performed with balloon dilation of the stricture to 15 mm. ERCP was then performed with CBD stone extraction. A 10 French by 7 cm biliary stent was placed into the CBD. A follow-up ERCP two months later showed stent migration into the proximal CBD. The migrated stent was attempted to be removed using an extraction balloon and rat-tooth forceps but was unsuccessful. A repeat ERCP was attempted by a different provider. However, ERCP scope could not be advanced beyond the severe esophageal stricture despite balloon dilation. The patient was then referred to us. ERCP was performed after stricture dilation to 15 mm. The scalp film showed the biliary stent in the epigastric region concerning for proximal stent migration. Endoscopic visualization showed peri-ambiliary diverticulum without biliary stent at the major papilla, suggestive of proximal stent migration. A cholangiogram confirmed the stent migration into the left intrahepatic duct. Direct cholangioscopy was planned at this point for stent retrieval. Direct cholangioscopy showed the distal portion of the stent in the common hepatic duct with the proximal portion extending into the left hepatic duct. A mini-snare was passed through the channel of the cholangioscope to grasp the distal phalange of the plastic biliary stent. The stent was mobilized towards the duodenum distally by gentle traction by withdrawing the cholangioscope and was removed successfully. Case 2, 74-year-old man with pancreatic adenocarcinoma complicated by malignant biliary stricture underwent an ERCP with plastic biliary stent placement. He had a cholecystectomy in the past. He presented two months later for repeat ERCP for stent exchange. The indwelling plastic biliary stent was removed successfully. Calangiogram showed a moderate distal CBD stricture. A 10 French by seven centimeter plastic biliary stent was attempted to be placed, but during deployment, it inadvertently migrated into the CBD proximal to the stricture. An extraction balloon was used to retrieve the proximally migrated stent. However, it was unsuccessful despite multiple attempts. A second biliary stent measuring 10 French by seven centimeters was placed at this point, traversing the stricture across the major papilla. We were called in at this point for a second opinion. Fluoroscopy here shows approximately migrated stent in the left intrahepatic as shown by the yellow and blue arrow and the newly placed plastic biliary stent across the major papilla as shown by the red arrow. There was concern for stent penetrating into the Gleason's capsule of the liver as shown by the blue arrow. Although it could just be located in the left interior branch within the liver. We decided to perform direct cholangioscopy for removal of the proximally migrated stent. The newly placed trans-papillary biliary stent was removed prior to the direct cholangioscopy. Cholangioscopy showed sludge and small stones in the proximal CBD. The distal end of the migrated stent was noted to be in the left main hepatic duct. Many forceps were passed through the channel of the direct cholangioscope and the distal end of the stent was grasped and the cholangioscope was withdrawn with gentle traction. The stent was successfully mobilized distally into the second portion of the duodenum and eventually retrieved. A 10mm by 6cm fully covered biliary metal stent was placed traversing the biliary stricture as shown here in this picture. The patient was observed overnight in the hospital. He received IV antibiotics and remained asymptomatic the next day and tolerated a diet. He was eventually discharged home on oral antibiotics. Detailed fluoroscopic examination is required for identification and location of the migrated stent and selection of an appropriate method for stent retrieval. Endoscopists should be aware that when an extraction balloon is used to retrieve the migrated stent, there is tendency for the stent to get pushed inwards into the intra-hepatic ducts as it likely happened in our cases. Single operator palangioscopy facilitates direct visualization and hence identification of exact location of the stent. Selection of accessory tools such as a mini snare or mini forceps depends on the location and position of the stent. Single operator palangioscopy should be performed with caution if there is a distal CBD stricture which may require dilation prior to the single operator palangioscopy. Based on our experience, single operator palangioscopy might be the safest and best initial method of retrieving proximally migrated biliary stents in appropriately selected cases, although further data is required to support this recommendation.

endoscopic retrieval

proximally migrated biliary stents

single-operator cholangioscopy

complications

fluoroscopic examination