Clinical Case Summary
Placement of self-expandable metal stents (SEMS) is a standard treatment in the palliation of unresectable malignant biliary obstruction, whereas multidisciplinary oncology treatment prolongs patient survival. Consequently, the likelihood of stent-related complications has increased. Distal migration is a rare cause of stent dysfunction and SEMSs are relatively hard to extract after insertion. We present the management of a patient with dislocated SEMS using argon plasma coagulation (APC).
An 88-year-old man with unresectable ampullary cancer and consequential biliary stricture underwent a transpapillary placement of a 6-cm-long, 10-mm diameter uncovered SEMS (uSEMS).
Twelve months later, he presented to our department with vomiting. Given the high index of suspicion for stent dysfunction, a duodenoscopy was performed. Direct endoscopic visualization showed a distal 3-cm-long migration of the uSEMS. The distal end of uSEMS was firmly impacted in the contralateral duodenal wall resulting in reactive tissue ingrowth narrowing both the stent and the duodenal lumen. Significant malignant duodenal obstruction was detected below the dislocated uSEMS.
Subsequently, it was attempted to trim the distal 2 cm of the stent using an axial APC probe (power setting 80W, gas flow 0,8 L/min). The trimmed stent was removed with biopsy forceps. The procedure lasted 20 min, without immediate complications and the patient was discharged within 2 days.
One month after the procedure, the patient was readmitted with recurrent vomiting. Endoscopy revealed duodenal stricture below the papilla of Vater, due to malignant disease progression. Therefore, an 8-cm-long, 20-mm diameter duodenal SEMS placement was performed under simultaneous endoscopic and fluoroscopic control and symptoms were soon relieved.
This case highlights endoscopic APC stent trimming as an efficient procedure, which allows easy, reproducible and well−tolerated management of migrated uSEMS-related complications.
References
Fig. 1. Dislocated uSEMS and reactive tumor ingrowth
Fig. 2. (a) Trimming of the distal end using APC (b) the remaining stent in situ
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