Troubleshooting for endoscopic ultrasound-guided hepaticogastrostomy stent migration: Additional stenting by the partial stent-in-stent method

Stent migration into the abdominal cavity, one of the most serious procedural complications of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) [1], usually requires emergency surgery [2] [3].

No endoscopic troubleshooting technique for stent migration into the abdominal cavity with EUS-HGS has been established to date. Herein, we describe a safe and innovative rescue method for this complication.

The patient was a 60-year-old man with duodenal stenosis and biliary obstruction, for which he had undergone bile duct and duodenal stent placement. He developed obstructive jaundice due to stent misplacement; hence, EUS-HGS was performed ([Video 1]).

Video 1 This video shows safe and innovative rescue method for stent migration into the abdominal cavity during endoscopic ultrasound-guided hepaticogastrostomy and additional stenting by the partial stent-in-stent method.

A small quantity of ascites was also present. Puncture was performed from B2 using a 19G needle, and an 8-mm × 8-cm fully covered self-expanding metallic stent (FCSEMS; NIR Stent) was placed by the double-wire method. After the stent released, it could not be found inside the stomach, and radiography and EUS showed that it had migrated into the abdominal cavity ([Fig. 1]). An unsuccessful attempt at additional stent placement was made, and the guidewire also slipped out.

Fig. 1 a Endoscopic ultrasound-guided hepaticogastrostomy: 8-mm × 8-cm fully covered self-expanding metal stents (FCSEMSs) were placed, but the stent on the gastric side migrated into the abdominal cavity. b, c Endoscopic ultrasound (EUS) showed complete migration into the abdominal cavity.

To recover from the migration, a puncture was made aiming at the metal stent inside the intrahepatic bile duct, and a guidewire was inserted from the stent side into the stent lumen and bile duct ([Fig. 2]).

Fig. 2 a Aiming at the metal stent in the intrahepatic bile duct region, a puncture was made with a 19G needle. b The stent delivery device was inserted.

After blunt dilatation of the cell part of the metal stent with a catheter, an 8-mm × 8-cm FCSEMS was additionally inserted by the partial stent-in-stent method ([Fig. 3]). The procedure was completed by confirming the presence of the stent in the stomach ([Fig. 4]) and computed tomography (CT) ([Fig. 5]). After the procedure, the patient developed mild peritonitis, but this was alleviated with conservative treatment, and chemotherapy could be continued.

Fig. 3 a, b An additional 8-mm × 8-cm FCSEMS was inserted by the partial stent-in-stent method.

Fig. 4 a Schematic diagram of additional stenting by the partial stent-in-stent method. b Radiography of additional stenting by the partial stent-in-stent method.

Fig. 5 Computed tomography of additional stenting by the partial stent-in-stent method. The migrated stent is seen in the abdominal cavity and the additional stent in the stomach.

This technique should be borne in mind when troubleshooting EUS-HGS stent migration.

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Competing Interest

The authors declare that they have no conflict of interest.

Acknowledgments

This work was supported in part by The National Cancer Center Research and Development Fund (2022-A-16).

• References

• 1 Martins FP, Rossini LG, Ferrari AP. Migration of a covered metallic stent following endoscopic ultrasound-guided hepaticogastrostomy: fatal complication. Endoscopy 2010; 42: E126-127
• 2 Okuno N, Hara K, Mizuno N. et al. Stent migration into the peritoneal cavity following endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2015; 47: E311
• 3 Minaga K, Kitano M, Yamashita Y. et al. Stent migration into the abdominal cavity after EUS-guided hepaticogastrostomy. Gastrointest Endosc 2017; 85: 263-264

Publication History

Article published online:
14 October 2022