A 78-year-old woman presented with jaundice and cholangitis, having presented 3 years
previously with jaundice and hilar stricturing to a hospital elsewhere. The previous
episode had been managed as a suspected cholangiocarcinoma with percutaneous transhepatic
drainage followed by the insertion of overlapping self-expanding metal stents (SEMSs)
extending from the hilum into the duodenum. The stricture had not progressed during
3 years of follow-up and we assessed this to be a benign post-cholecystectomy stricture.
Computed tomography (CT) scanning revealed the overlapping biliary SEMSs, which were
obstructed by soft tissue, and multiple stones within and proximal to the stents.
Index endoscopic retrograde cholangiopancreatography (ERCP) identified a long portion
of stent extending distally into the duodenum and precluding cannulation ([Fig. 1]). Attempts to cannulate through the side of the SEMS were unsuccessful owing to
the tight overlapping mesh. The distal stent was not removable. The patient was considered
unsuitable for surgery and likely to require future biliary interventions, so improved
ERCP access was therefore required.
Fig. 1 Endoscopic view showing the overlapping biliary stent extending distally into the
duodenum.
A repeat ERCP was performed using a standard duodenoscope (ED34-i10T; Pentax, Tokyo,
Japan). The remOVE DC Cutter and the remOVE DC Impulse medical electrical device (Ovesco
Endoscopy AG, Tübingen, Germany) were used to circumferentially cut the SEMS, leaving
only a short stent portion protruding from the ampulla, which thereby allowed easy
ERCP access ([Video 1]). Balloon trawls were able to clear the stent of debris.
Video 1 The reMOVE DC cutter is used to trim the length of a biliary stent that was extending
distally and precluding cannulation at endoscopic retrograde cholangiopancreatography.
The remOVE cutter uses DC current for the removal of over-the-scope and full-thickness
resection clips [1]. The cutting of biliary stents using an endoscopic suture cutter [2] or argon plasma beam [3] has been previously described, but this is the first reported use of the remOVE
cutter to trim a biliary SEMS. We believe this is an effective method to provide endoscopic
biliary access when misplaced stents prevent this and cannot be removed.
Endoscopy_UCTN_Code_CPL_1AK_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
