Spontaneous intraductal stent migration after endoscopic ultrasound-guided choledochogastrostomy
22 March 2013 (online)
Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative method of biliary decompression . EUS-guided choledochogastrostomy (EUS-CGS) is considered a possible salvage therapy for patients in whom EUS-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) is not possible . We report a case of intraductal migration of a partially-covered self-expandable metallic stent (PCSEMS) after EUS-CGS, which was managed successfully with endoscopic intervention.
A 56-year-old woman with locally advanced cancer of the pancreatic head was admitted to our hospital. She had previously undergone a gastrojejunostomy and percutaneous biliary drainage for malignant gastric outlet obstruction and biliary obstruction at another hospital. Given her strong desire to have the external drainage tube removed and because EUS-CDS and EUS-HGS were impossible for anatomical reasons, she underwent EUS-CGS with insertion of a PCSEMS for internal biliary drainage without complications ([Fig. 1]; [Video 1]).
The external drainage tube was removed successfully 15 days after EUS-CGS, but 1 month later she developed acute cholangitis. An emergency endoscopy revealed that the PCSEMS had migrated into the bile duct ([Fig. 2]), which was confirmed on an abdominal radiograph ([Fig. 3]). The remaining fistula was successfully cannulated and a guidewire was advanced through the migrated PCSEMS into the intrahepatic bile duct. Another PCSEMS was placed across the fistula between the first PCSEMS and the stomach ([Fig. 4]; [Video 2]). The cholangitis subsided and she was discharged 3 days after the procedure without complications.
Spontaneous intraductal migration of a covered metallic stent after EUS-BD is a serious complication . We managed this successfully with endoscopic placement of a further PCSEMS across the resulting fistula. Because the extrahepatic bile duct and gastric antrum are not connected anatomically, we must be aware of this complication after EUS-CGS.
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