1390 Impacted Fully Covered Self-Expanding Metal Biliary Stent Within an Uncovered Metal Stent by Exuberant Granulation Tissue Growth Successfully Removed After Treatment With Argon Plasma Coagulation (APC)

INTRODUCTION: We describe the case of an impacted, fully covered, self-expanding metal biliary stent within an uncovered metal stent because of exuberant granulation tissue growth at the ampullary orifice. The stent was successfully removed after treatment of granulation tissue with Argon Plasma Coagulation (APC). CASE DESCRIPTION/METHODS: A 95-year-old lady underwent placement of an uncovered self-expanding metal stent for a tight stricture of the distal bile duct by another gastroenterologist several years ago. The stricture was initially felt to be a malignant stricture but subsequently turned out to be a benign stricture. However, the biliary tree was frequently obstructed with excessive tissue ingrowth and recurrent stone formation requiring placement of a fully-covered self expanding metal stent within the uncovered metal stent, exchanged every nine months. During one of the ERCPs for stent exchange, the covered metal stent could not be removed because of exuberant growth of granulation tissue around the ampullary orifice covering the edges of the stent. The stent was left in place, the stones were extracted with a stone-extraction balloon and the granulation tissue was treated with APC. The plan was to bring the patient back for an ERCP and stent exchange after resolution of the granulation tissue. The patient ended up being hospitalized with stent occlusion and cholangitis after three months. At that time an ERCP was performed and the granulation tissue was noted to have completely resolved. The stent was occluded with stones and debris. The stent was removed without difficulty and a new stent was placed. The same exact situation recurred two years later. The granulation tissue was treated again with APC and stent was cleaned out with a stone-extraction balloon. The patient was brought back in three months for an ERCP and easy stent removal. DISCUSSION: Fully covered self-expanding metal stents have been used successfully for a variety of malignant and benign conditions and are generally easily removable. Occasionally exuberant growth of granulation tissue at the biliary orifice can preclude stent removal. Attempts to remove the stent forcibly can result in stent disruption and can lead to serious complications. In these situations the best approach is to treat the granulation tissue with APC and bring the patient back after resolution of the granulation tissue for an easy stent exchange.