Snare-over-scope technique for retrieval of a proximally migrated biliary stent

There is no consensus on the optimal technique for retrieval of proximally migrated biliary stents. A biliary sphincterotomy or sphincteroplasty, together with the use of accessories such as stent-grasping forceps, Soehendra stent retrieval device, and stone extraction balloon, have been reported [1] [2] [3] [4]. We present the case of a proximally migrated biliary stent that was retrieved using a novel “snare-over-scope” (SOS) technique.

A 25-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP), which revealed a 5-mm common hepatic duct stricture caused by extrinsic compression from a periportal lymph node ([Fig. 1]). Consequently, a 10 Fr × 9 cm, straight, plastic stent was deployed across the stricture ([Fig. 2]).

Fig. 1 Cholangiogram demonstrating a 5-mm biliary stricture in the common hepatic duct (arrow).

Fig. 2 Biliary stent deployed in the optimal position across the stricture (arrow).

The patient’s clinical and biochemical parameters did not resolve, and repeat ERCP was performed revealing proximal migration of the stent ([Fig. 3]). Despite extension of the biliary sphincterotomy and sphincteroplasty to 12 mm, and the use of stent-grasping forceps, the stent could not be retrieved. On several occasions, the stone extraction balloon was able to drag the stent out through the major papilla, but when the balloon was deflated to exchange it for a snare, the stent slipped back into the bile duct.

Fig. 3 Cholangiogram demonstrating biliary sphincteroplasty. The proximally migrated 10 Fr × 9 cm, plastic stent is seen entirely within the bile duct (arrow).

It was recognized that the stent had to be stabilized within the duodenum prior to grasping. A polypectomy snare was taped to the exterior of the duodenoscope, oriented along the biopsy channel and with the snare closed around the tip of the scope ([Fig. 4], [Video 1]). The duodenoscope with snare was advanced as a single unit to the major papilla. The stent was brought out through the biliary orifice using the inflated stone extraction balloon, and the snare was opened and closed around the stent ([Fig. 5]). The balloon was deflated and the endoscope, together with the snare grasping the stent, was removed from the patient. A 10 Fr × 12 cm, straight, plastic stent was then inserted across the stricture with ample length remaining in the duodenum.

Fig. 4 In vitro image demonstrating the polypectomy snare taped to the exterior of the duodenoscope along the biopsy channel, with the snare closed around the tip of the scope.

Demonstration of the equipment set-up and the stent being removed from the bile duct using the “snare-over-scope” technique.

Fig. 5 Snare closed around the stent.

This case demonstrates the innovative SOS technique, which effectively creates a second over-the-scope port, allowing an accessory to be used to secure and retrieve a biliary stent. This technique could also be employed for stents that have migrated proximally into the pancreatic duct.

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• References

• 1 Sakai Y, Tsuyuguchi T, Ishihara T et al. Cholangiopancreatography troubleshooting: the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents. Hepatobiliary Pancreat Dis Int 2009; 8: 632-637
• 2 Katsinelos P, Kountouras J, Paroutoglou G et al. Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers. Surg Laparosc Endosc Percutan Tech 2009; 19: 217-221
• 3 Vila JJ, Ruiz-Clavijo D, Fernández-Urién I et al. Endoscopic retrieval of a proximally migrated pancreatic stent: variation of the lasso technique. Endoscopy 2010; 42: E5-E6
• 4 Nakai Y, Isayama H, Kawakubo K et al. Endoscopic removal of a biliary covered metallic stent with the invagination method. Endoscopy 2011; 43: E30-31