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MANAGEMENT OF A MIGRATED AND BLOCKED METALLIC BILIARY STENT USING ARGON PLASMA COAGULATOR A CASE REPORT
P Tiwari, WP Pais, MR Kowal, ML Bechtold, C Bartalos, D Antillon, MR Antillon
Division of Gastroenterology University of Missouri-Columbia Columbia, MO, USA
BACKGROUND: Distal or proximal migration/erosion is a complication after insertion of a self-expandable metallic stent (SEMS) in the biliary tract. Stent repositioning or removal is not always possible, especially in case of metal stents. Therefore, cutting of the stent using argon plasma coagulation (APC) may be a good alternative to surgery to solve this problem. Successful removal of metal stents with minimal biliary thermal injury has been reported in pig models. We are reporting a case of successful management of distally migrated biliary mental stent eroding into the duodenal wall.
Case report: 71 year-old female with a history of chronic pancreatitis and metastatic bronchoalveolar carcinoma causing extrinsic common bile duct (CBD) compression presented to our gastroenterology clinic with worsening of abdominal pain over a four-month period. She had previously undergone an ERCP with metallic stent placement at an outside facility a few months prior to her presentation. The patient subsequently underwent a repeat ERCP at our facility which revealed migrated metal and plastic stents that were impacted and eroded into the duodenal wall. The plastic stent was carefully mobilized with a balloon from the impaction site, was snared, and subsequently removed. The metal stent was also mobilized from the eroded duodenal wall site but attempts to remove the impacted metal stent with grasper forceps were unsuccessful. The stent appeared to be clogged. We applied APC using ERBE VIO APC2 device with ERBE FiAPC probe w filter (20132-217) to the stent with 120 Watts energy and cut the metal stent to relieve impaction and erosion into the duodenal wall. The dissected piece of the metal stent was retrieved with a forceps using a protector over-tube to avoid damage to the upper esophagus. Guidewire cannulation through the remaining portion of the metal stent was achieved. The debris in the stent lumen was removed with multiple passes of a 9-12 mm biliary balloon and a subsequent cholangiogram was obtained. Two Zimmons (10-Fr, 10 cm and 7-Fr, 10 cm) plastic stents we introduced inside the remaining portion of the metal stent, successfully ensuring adequate drainage. There were no complications.
CONCLUSIONS: Our experience suggests that the APC can be used to cut and remove migrated biliary metal stents. No immediate evidence of thermal injury was noted in our patient.