Usefulness of a circumferential argon plasma coagulation probe in trimming a dislocated distal biliary metal stent

A 69-year-old man with unresectable cancer of the pancreatic head presented to our hospital with fever and jaundice. A laser-cut fully covered self-expandable metal stent (LC-SEMS; X-Suit NIR covered biliary metal stent; Olympus Medical Systems, Tokyo, Japan) and a duodenal metal stent (Niti-S pyloric/duodenal uncovered stent; Taewoong Medical, Seoul, South Korea) had been placed 12 months previously for malignant biliary and duodenal strictures, respectively.

A computed tomography scan revealed LC-SEMS occlusion ([Fig. 1]). We therefore attempted to remove the stent using a balloon catheter (Extractor ProRX; Boston Scientific, Marlborough, Massachusetts, USA) and a snare (SD-5U-1; Olympus Medical Systems); however, the stent could not be removed and broke, resulting in its dislocation to the duodenal side ([Fig. 2]). We therefore abandoned stent removal and attempted to trim the LC-SEMS using a circumferential argon plasma coagulation (APC) probe (FiAPC probe; 80 W with a flow rate of 1.2 L/min; ERBE Elektromedizin, Tübingen, Germany) ([Fig. 3]). This APC probe has an insulator ball at the tip, similar to the insulated-tip knife used for endoscopic submucosal dissection [1]. We hooked the insulator ball onto the mesh of the LC-SEMS, and cut the stent by pulling the probe. The LC-SEMS was very easily trimmed, and the procedure was completed within 10 minutes without any complications ([Video 1]). Later, a new LC-SEMS was placed over the previous one.

Fig. 1 Computed tomography image showing the occluded laser-cut fully covered self-expandable metal stent (yellow arrowheads).

Fig. 2 Duodenoscopy image showing the extension of the stent into the duodenum after its attempted removal.

Fig. 3 Photographs of the FiAPC probe (ERBE Elektromedizin, Tübingen, Germany).

Video 1 A laser-cut fully covered self-expandable metal stent is trimmed using a circumferential argon plasma coagulation probe.

The application of APC to trim various SEMSs has been previously reportedly [2] [3] [4]. In the present case, the insulating ball allowed us to avoid damage to the duodenal mucosa and safely cut the LC-SEMS by pulling the probe. Moreover, the shortening of the procedure time can be expected to prevent mucosal damage of the bile duct from heat conduction during the APC [5]. The circumferential APC probe enables safe and easy trimming of biliary metal stents.

Endoscopy_UCTN_Code_CPL_1AK_2AD

• References

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• 2 Demarquay JF, Dumas R, Peten EP. et al. Argon plasma endoscopic section of biliary metallic prostheses. Endoscopy 2001; 33: 289-290
• 3 Vanbiervliet G, Piche T, Caroli-Bosc F. et al. Endoscopic argon plasma trimming of biliary and gastrointestinal metallic stents. Endoscopy 2005; 37: 434-438
• 4 Christiaens P, Decock S, Buchel O. et al. Endoscopic trimming of metallic stents with the use of argon plasma. Gastrointest Endosc 2008; 67: 369-371
• 5 Chen YK, Jakribettuu V, Springer EW. et al. Safety and efficacy of argon plasma coagulation trimming of malpositioned and migrated biliary metal stents: a controlled study in the porcine model. Am J Gastroenterol 2006; 101: 2025-2030