Endoscopic Retrieval of Proximally Migrated Plastic Biliary Stent With Over-The-Wire Snare Technique

CASE REPORT Biliary stents migration rate is about 5%–10%, in particular the migration of plastic biliary stent is reported to be up to 13.5%. Of the latter, proximal migration is less frequent than distal migration, but, when it occurs, it is often symptomatic and requires endoscopic retrieval.1,2 The risk factors associated with stent migration are categorized into patient-related and stent-related risk factors. The risk factors linked to the patient's characteristics are the dilation of the common bile duct (CBD) (>1 cm), the presence of distal benign strictures, and if these strictures has been previously dilated. Regarding the specific characteristics of plastic stents, it has been observed that straight, larger, and longer stents are associated with higher migration rates. Various techniques have been reported to treat proximal plastic stent migration, and resolution rates appear of up to 90% of cases. The retrieval techniques include forceps, Dormia basket, snare, Soehendra stent retriever, and balloon.1–4 An 88-year-old woman was admitted to our hospital to perform an endoscopic retrograde cholangiopancreatography for the removal of a plastic biliary stent (10 Fr × 7 cm) placed 2 months earlier for difficult choledocholithiasis and to complete clearance of CBD. On evaluation of the papillary area, the stent was not visible, and cholangiography showed the proximal migration of the stent with the proximal end of the stent positioned at the left hepatic duct and an associated CBD dilation up to about 25 mm with large stones approximately 20 × 30 mm at the level of the middle CBD. Various attempts were made to remove the stent: a first attempt was made with a Fogarty balloon, without success due to difficulty to give the right strength on the stent due to the large size of CBD. A second unsuccessful attempt was made with a basket, due to difficulty in directing the device toward the stent inside a dilated CBD with large stones. The left intrahepatic duct was therefore cannulated with a Guidewire, and a polypectomy snare was inserted over the wire, capturing the distal end of the stent and obtaining an easy extraction (Figure 1) (Video1).Figure 1.: (A) Proximal migration of the stent with the proximal end of the stent positioned at the left hepatic duct. (B) Unsuccessful attempt was made with a basket, due to difficulty in directing the device toward the stent inside a dilated CBD with large stones. (C) Fogarty balloon attempts, without success due to difficulty to give the right strength on the stent due to the large size of CBD and, in addition, to difficulty in releasing the proximal flap, which was stuck at the bifurcation of the right intrahepatic duct for the second and third segments. (D) A polypectomy snare was inserted over the wire. CBD, common bile duct. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Endoscopic retrieval of proximally migrated plastic biliary stent with over-the-wire snare technique.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_7joz64yj"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} In our case, the difficulty in stent retrieval was due to the size of the CBD and the limitations of the device's maneuverability in presence of a large stone occupying almost all the CBD. In our opinion, the advantage of the over-the-wire snare technique for retrieval of proximally migrated plastic biliary stent comes from the lower rigidity of the snare and therefore better maneuverability compared with the basket. Furthermore, it facilitates the operator to direct the Guidewire into the desired hepatic ducts and helps to exerts a greater force on the stent in the retraction phase compared with the balloon, particularly when the bile duct is much dilated. At the end of the procedure, we did not observe any injury of the CBD, and no adverse events were observed during the hospital stay. DISCLOSURES Author contributions: T. Antenucci and R. Arena: Substantial contributions to the conception or design of the work and drafting the work; A. Diotaiuti, C. Distabile, R. Solimando, and V. Cifala reviewing the manuscript; A. Merighi: Final approval of the version to be published. R. Arena is the article guarantor. Financial disclosure: None to report. Data availability: The data supporting the findings of this study are available upon reasonable request from the corresponding author. Informed consent was obtained for this case report.