Case Series on an Emerging Procedure: Endoscopic Removal of Uncovered Biliary Self-Expandable Metal Stents

Le résumé fourni par la source

Unresectable malignant biliary obstruction can be treated with palliative placement of self-expandable metal stents (SEMS). Uncovered SEMS are used for this purpose and usually are not retrievable by endoscopic means. We now present 2 cases of endoscopic removal of uncovered biliary SEMS. Case 1: 76 year old woman with elevated liver enzymes thought to be due to cancer underwent placement of uncovered SEMS 5 years ago was found to have sclerosing cholangitis as the etiology. In order to remove the uncovered SEMS, a 10x60mm fully covered Wallflex stent was placed inside the uncovered SEMS. Two months later, both the covered and uncovered biliary SEMS were removed simultaneously using a rat-toothed forceps. She was asymptomatic on 2-month follow-up. Case 2: 67 year old man with head of pancreas mass thought to be malignant underwent placement of an uncovered SEMS. He was subsequently diagnosed with autoimmune pancreatitis on biopsy and treated with steroids. Three months after the uncovered SEMS placement, he was hospitalized for fever and diffuse abdominal pain concerning for ascending cholangitis. ERCP showed the stent was partially occluded and completely ingrown at the papilla. Debris was cleared with balloon extraction and a 10x80mm fully covered SEMS was placed within the uncovered SEMS. A month later, both biliary stents were retrieved in one session using a rat-toothed forceps. The fully covered SEMS was removed first, followed by the uncovered SEMS. A month later he again returned to the ER with fever and elevated alkaline phosphatase. ERCP showed a widely patent opening to the bile duct. Two strictures were found, one in the distal CBD and the other just proximal to the cystic duct. A fully covered Wallflex stent was placed traversing both strictures. SEMS are associated with long-term complications if not removed, which include stent migration, stent occlusion, and cholangitis. There has been only one prior report in the literature describing removal of an intact uncovered SEMS 8 weeks after being placed. Our case series represents the first cases in which the uncovered biliary SEMS was removed greater than 8 weeks after initial placement. No complications were seen in the first case. Biliary strictures developed in the second case but the previously stented area was patent.

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