Endoscopy 2013; 45(S 02): E89-E90
DOI: 10.1055/s-0032-1326255
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Spontaneous intraductal stent migration after endoscopic ultrasound-guided choledochogastrostomy

K. Kawakubo
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
H. Kawakami
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
M. Kuwatani
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
S. Haba
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
T. Kudo
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Y. Abe
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
N. Sakamoto
Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
› Author Affiliations
Further Information

Corresponding author

H. Kawakami, MD
Department of Gastroenterology and Hepatology
Hokkaido University Graduate School of Medicine
Kita 15, Nishi 7, Kita-ku
Sapporo 060-8638
Japan   
Fax: +81-11-7067867   

Publication History

Publication Date:
22 March 2013 (online)

 

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative method of biliary decompression [1]. EUS-guided choledochogastrostomy (EUS-CGS) is considered a possible salvage therapy for patients in whom EUS-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) is not possible [2]. We report a case of intraductal migration of a partially-covered self-expandable metallic stent (PCSEMS) after EUS-CGS, which was managed successfully with endoscopic intervention.

A 56-year-old woman with locally advanced cancer of the pancreatic head was admitted to our hospital. She had previously undergone a gastrojejunostomy and percutaneous biliary drainage for malignant gastric outlet obstruction and biliary obstruction at another hospital. Given her strong desire to have the external drainage tube removed and because EUS-CDS and EUS-HGS were impossible for anatomical reasons, she underwent EUS-CGS with insertion of a PCSEMS for internal biliary drainage without complications ([Fig. 1]; [Video 1]).

Zoom Image
Fig. 1 Abdominal radiograph showing a partially covered self-expanding metal stent in position between the extrahepatic bile duct and the gastric antrum.


Quality:
Endoscopic ultrasound-guided choledochogastrostomy (EUS-CGS) using a partially-covered self-expandable metallic stent (PCSEMS).

The external drainage tube was removed successfully 15 days after EUS-CGS, but 1 month later she developed acute cholangitis. An emergency endoscopy revealed that the PCSEMS had migrated into the bile duct ([Fig. 2]), which was confirmed on an abdominal radiograph ([Fig. 3]). The remaining fistula was successfully cannulated and a guidewire was advanced through the migrated PCSEMS into the intrahepatic bile duct. Another PCSEMS was placed across the fistula between the first PCSEMS and the stomach ([Fig. 4]; [Video 2]). The cholangitis subsided and she was discharged 3 days after the procedure without complications.

Zoom Image
Fig. 2 Endoscopic view 1 month after formation of the choledochogastrostomy showing the partially covered self-expanding metal stent that had migrated into the bile duct.
Zoom Image
Fig. 3 Abdominal radiograph showing the distal end of the partially-covered self-expandable metallic stent located inside the fistula.
Zoom Image
Fig. 4 Abdominal radiograph showing a second partially-covered self-expandable metallic stent (PCSEMS) placed across the fistula between the first PCSEMS and the stomach.


Quality:
Placement of a second partially-covered self-expandable metallic stent (PCSEMS), which was positioned across the fistula between the first PCSEMS and the stomach.

Spontaneous intraductal migration of a covered metallic stent after EUS-BD is a serious complication [3]. We managed this successfully with endoscopic placement of a further PCSEMS across the resulting fistula. Because the extrahepatic bile duct and gastric antrum are not connected anatomically, we must be aware of this complication after EUS-CGS.

Endoscopy_UCTN_Code_CPL_1AK_2AJ


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Competing interests: None


Corresponding author

H. Kawakami, MD
Department of Gastroenterology and Hepatology
Hokkaido University Graduate School of Medicine
Kita 15, Nishi 7, Kita-ku
Sapporo 060-8638
Japan   
Fax: +81-11-7067867   


Zoom Image
Fig. 1 Abdominal radiograph showing a partially covered self-expanding metal stent in position between the extrahepatic bile duct and the gastric antrum.
Zoom Image
Fig. 2 Endoscopic view 1 month after formation of the choledochogastrostomy showing the partially covered self-expanding metal stent that had migrated into the bile duct.
Zoom Image
Fig. 3 Abdominal radiograph showing the distal end of the partially-covered self-expandable metallic stent located inside the fistula.
Zoom Image
Fig. 4 Abdominal radiograph showing a second partially-covered self-expandable metallic stent (PCSEMS) placed across the fistula between the first PCSEMS and the stomach.