Plastic stents (PSs) are used in patients with malignant hilar obstruction (MHO), considering patient life expectancy and reintervention [1]
[2]. Some PSs are designed for suprapapillary stenting and are equipped for thread removal for reintervention [3]. Here, we present a case that illustrates rare problems caused by the removal of the thread adhering to the duodenoscope elevator identified using the double-scope technique [4].
A 65-year-old man with Bismuth type I MHO due to unresectable gallbladder cancer ([Fig. 1]) underwent suprapapillary stenting in a side-by-side fashion using a dedicated PS
(Through & Pass, 7F Inside Stent; Gadelius Medical, Tokyo, Japan) ([Fig. 2]
a, [Fig. 2]
b, [Video 1]). The duodenoscope (TJF-Q290V; Olympus, Tokyo, Japan) was extubated after we washed the
removing threads out of the scope channel. However, extubation suddenly became disrupted in the
stomach ([Video 1]). To identify the cause, a second ultra-slim esophagogastroduodenoscope was inserted
along the duodenoscope. We determined that the thread jammed beside the immobile elevator in the
lifted position ([Fig. 3]
a, [Fig. 3]
b, [Video 1]). Finally, repetitive striking of the lifted elevator with a cannula loosened the fixed
elevator and released the thread ([Video 1]).
A stent-removing thread sticking adjacent to the duodenoscope elevator identified using the double-scope technique.Video 1
Fig. 1 Abdominal computed tomography. Computed tomography revealed bilateral dilated intrahepatic bile ducts caused by gallbladder cancer, which also invaded the right lobe.
Fig. 2 Fluoroscopic image with a duodenoscopic view after inside plastic stent deployment. a Fluoroscopic image demonstrating double-inside plastic stent indwelling at the hilar stricture in a side-by-side position. b In the duodenoscopic view, four removal threads of the plastic stents were washed into the appropriate lumen.
Fig. 3 An ultra-slim endoscope confirms the locked removing thread beside the fixed elevator. a Fluoroscopic image demonstrating rendezvous of the duodenoscope and ultra-slim scope. b In the ultra-slim endoscopic view, the thread was visibly locked beside the lifted and fixed elevator. The solid red arrow indicates an impacted thread. The red dotted arrow indicates an elevator.
During the release of the stent-removing threads, these threads potentially fall into the slit between the scope elevator and side wall. If the operator lifts the elevator in this position, the thread jams tightly in the slit ([Video 1]), which disrupts scope extubation. In this situation, we must avoid pulling the scope violently; otherwise, the impacted thread tears the papilla and duodenum upward. This event develops outside the duodenoscope view; therefore, in cases of incomprehensible disruption of scope extubation, the double-scope technique will clarify the reason.
