A 75-year-old man presented with hematemesis and melena. He had received an uncovered
nitinol self-expanding metal stent (SEMS) 2 months previously for inoperable obstructive
hilar cholangiocarcinoma.
Upper endoscopy revealed a normal esophagus, stomach, and duodenal bulb. At the duodenal
wall opposite the papilla, a large ulceration with hematin spot ([Fig. 1]) had formed as a result of SEMS impaction. We decided to shorten the stent with
argon plasma coagulation (APC). For this procedure we used a duodenoscope and an ERBE
generator (APC settings: power 80 W, flow rate 1.8 l/minute). The section was done
circumferentially 1 cm from the papilla ([Fig. 2]), and the stent was shortened by 1.5 cm ([Fig. 3]). During his hospitalization the patient was making progress and his hematocrit
was stable. He was discharged 4 days later.
Fig. 1 The stent protruding far from the papilla. A deep ulceration is visible at the duodenal
wall opposite the papilla.
Fig. 2 Half-way through cutting the stent. The ulceration is also visible as is the argon
plasma coagulation catheter.
Fig. 3 Final result of cutting the stent. The fragmented piece is afterwards withdrawn along
with the scope.
He presented again to our hospital the next day with massive hematemesis and melena.
At admission he was already in severe oligemic shock and succumbed shortly afterwards.
Ulceration is caused by continuous mechanical irritation of the mucosa opposite the
distal end of the stent. Distal migration or malpositioning are the causes of this
complication. Furthermore, mucosal ulceration may be promoted by the sharp edges of
metal stents [1]. To date, several cases of ulceration and bleeding caused by biliary SEMS have been
reported [1]
[2]
[3]. In most cases, bleeding was self-limiting. When indicated, endoscopic hemostasis
successfully arrested the bleeding. APC is reported to be a safe, effective, and easy
way to reduce stent length [2]
[3]
[4]. Shortening of the stent, with or without endoscopic hemostasis, was enough to permanently
correct the complication in the published cases. Fatal bleeding from SEMS-induced
ulceration has never been reported, let alone after endoscopic trimming with APC.
Metal stents are a valuable means of restoring the continuity of the biliary tract.
Choosing the correct size and accurate positioning are key factors to reducing complications.
Furthermore, metal stents with rounded edges could reduce the risk of ulceration.
Finally, longer hospitalization may be advisable when treating SEMS-induced bleeding
ulcers.
Endoscopy_UCTN_Code_CPL_1AK_2AD
