Rescue technique using a diathermic dilator for an unremovable stent in malignant perihilar biliary obstruction

Endoscopic biliary stenting is a useful and safe technique for malignant biliary obstructions. A plastic stent is frequently used because of its low cost and ease of deployment. However, it is occasionally difficult to remove a plastic stent because of severe stricture. We describe a rescue technique for immovable plastic stents, using a diathermic dilator in a case of perihilar biliary obstruction.

A 63-year-old woman with jaundice due to hilar biliary obstruction was referred to our hospital. A diagnosis of gallbladder cancer was made from findings of a thickened gallbladder wall and massive ascites revealed by computed tomography ([Fig. 1]) and magnetic resonance cholangiopancreatography ([Fig. 2]). For biliary decompression and pathological confirmation, endoscopic retrograde cholangiography (ERC) was performed, and a 7-Fr plastic stent was placed ([Fig. 3], [Video 1]).

Fig. 1 Contrast-enhanced computed tomography showed a thickened gallbladder wall and massive ascites.

Fig. 2 Magnetic resonance cholangiopancreatography showed a perihilar biliary stricture with dilation of the intrahepatic bile duct.

Fig. 3 Radiographic images. a The perihilar biliary stricture. b A 7-Fr plastic stent was placed across the perihilar biliary stricture (inset: endoscopic view of the plastic stent through the ampulla of Vater).

Video 1: A plastic stent was placed during the first endoscopic retrograde cholangiography (ERC) for malignant perihilar biliary obstruction. At the second ERC, the plastic stent could not be removed and a sphincterotome could not be advanced through the perihilar biliary obstruction. However, a 6-Fr diathermic dilator could be advanced beyond the perihilar biliary obstruction. Finally, a partially covered, self-expandable, metallic stent was placed successfully alongside the plastic stent.

The patient underwent a second ERC 4 days later because of elevated biliary enzymes. The plastic stent could not be removed using forceps and snares, and the torn-off stent was left in place ([Fig. 4]). Although needle-knife sphincterotomy was performed to expose the residual plastic stent, the stent could not be grasped. A 0.025-inch guidewire could be advanced alongside the plastic stent, but a sphincterotome (CleverCut 3V; Olympus, Tokyo, Japan) could not. Successful dilation of the perihilar biliary stricture was achieved by advancing a 6-Fr wire-guided diathermic dilator (Cysto-Gastro-Set; Endo-Flex GmbH, Voerde, Germany) ([Fig. 5]). However, the remaining plastic stent also migrated. Thus, a 10-mm lumen partially covered, self-expandable, metallic stent (WallFlex biliary stent; Boston Scientific Japan, Tokyo, Japan) was deployed alongside the plastic stent ([Fig. 6]).

Fig. 4 Endoscopic images. a Snaring of the plastic stent after precut sphincterotomy with a needle-knife. b The torn-off plastic stent was left in place.

Fig. 5 Radiographic images. a A 0.025-inch guidewire was advanced alongside the plastic stent (inset: endoscopic view). b, c A 6-Fr diathermic dilator was advanced alongside the perihilar biliary stricture (inset: endoscopic view).

Fig. 6 Radiographic images showing the partially covered, self-expandable, metallic stent placed over the stricture alongside the plastic stent.

In cases of malignant biliary stricture, removal of a plastic stent is time-consuming and might cause complications. The usefulness of a diathermic dilator for severe biliary strictures has been reported [1] [2] [3] [4] [5]. The use of diathermic dilation is also an effective rescue technique for unremovable occluded plastic stents.

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• References

• 1 Kawakami H, Kuwatani M, Eto K. et al. Resolution of a refractory severe biliary stricture using a diathermic sheath. Endoscopy 2012; 44 (Suppl. 02) E119-120
• 2 Kawakami H, Kuwatani M, Kawakubo K. et al. Transpapillary dilation of refractory severe biliary stricture or main pancreatic duct by using a wire-guided diathermic dilator (with video). Gastrointest Endosc 2014; 79: 338-343
• 3 Kawakami H, Kuwatani M, Sakamoto N. Endoscopic ultrasound-guided antegrade diathermic dilation followed by self-expandable metallic stent placement for anastomotic stricture after hepaticojejunostomy (with video). Dig Endosc 2014; 26: 121-122
• 4 Kawakami H, Kuwatani M, Kawakubo K. et al. Endoscopic ultrasound-guided antegrade diathermic dilation followed by self-expandable metal stent placement for malignant distal biliary stricture. Endoscopy 2014; 46 (Suppl. 01) E328-329
• 5 Kawakami H, Abo D, Kawakubo K. et al. Rendezvous biliary recanalization combining percutaneous and endoscopic techniques using a diathermic dilator for bile duct obstruction. Endoscopy 2014; 46 (Suppl. 01) E460-461