Biliary Cannulation Using the Ultra-thin Endoscope for Removal of a Proximally Migrated Fully Covered Self-expanding Metal Stent

Biliary stenting is common practice today and knowing about the potential complications of stent migration is crucial to any training gastroenterologist. We present a 54-year-old male with a history of recurrent biliary obstruction secondary to choledocholithiasis who had a FCSEMS placed after no improvement post-sphincterotomy and multiple plastic biliary stents. Six months later the patient presented back for elective ERCP with stent removal but the stent was found to have internally migrated. There were attempts to remove the stent with a snare, rat tooth forceps, and digital cholangioscopy to no avail. Therefore, a second FCSEMS was placed for drainage. The patient was then brought back 5 months later for an attempt at stent removal. The distal placed stent was easily removed with a rat tooth forceps; however, the proximal stent was unable to be removed secondary to stricture formation at the distal end. Balloon dilation of the stricture was performed followed by a failed attempt to remove the stent using a CRE balloon. The digital cholangioscope was then used to identify the distal end of the stent and the 1 mm spy bite forceps was used to grasp the stent but it was unable to maintain a grip during traction on the stent. Finally, we used the ultra-thin Olympus GIF-N230 endoscope to freely cannulate the bile duct and identify the distal end of the stent. There was obvious inflammatory tissue change with stricture which prevented stent removal. Using the 2 mm pediatric biopsy forceps we were able to grasp the end of the stent and, with a moderate amount of force, were able to remove the stent. On repeat cannulation with the ultra-thin scope and direct visualization of the bile duct, there was minimal trauma with only mild oozing. Stent migration into the proximal biliary system is a known complication with placement and there are a number of techniques described in the literature for retrieval/removal of stents. Typically, indirect traction with a balloon or direct grasping with a wire basket, snare, or forceps is successful in retrieving migrated stents. Removal of stents with direct peroral cholangioscopy is rare in the literature but is a potentially useful tool for difficult to remove stents secondary to strictures as in our patient. There are little case reports detailing extraction of FCSEMS with the ultraslim endoscope and this case report supports the use of direct cholangioscopy for biliary intervention including but not limited to stent removal.Figure: SpyGlass.Figure: Direct cholangioscopy showing the CBD and metal stent.Figure: Direct cholangioscopy showing the CBD, metal stent, and biopsy forceps.