S4169 Large Caliber Electrohydraulic Lithotripsy (EHL)-Assisted Removal of a Twelve-Years Retained Internally Migrated 10-Fr Plastic Biliary Stent: A Novel Use of EHL When All Else Fails

Introduction: Internally migrated biliary stent is an endoscopic retrograde cholangiopancreatography (ERCP) related complication that requires intervention. Prolonged retention of internally migrated stents may complicate removal, often necessitating advanced endoscopic techniques. We present the case of a retained biliary stent for 12 years, ultimately requiring removal via a large channel rotatable pancreaticobiliary cholangioscope. Case Description/Methods: A 45-year-old woman with a history of pregnancy-related choledocholithiasis, managed with cholecystectomy and common bile duct (CBD) stent placement 12 years prior, but was lost to follow-up. She presented with worsening right upper quadrant pain. A computed tomography (CT) revealed extensive choledocholithiasis extending to the biliary bifurcation, CBD, and intrahepatic ductal dilation, pneumobilia, with a retained CBD stent (CT image in video). Magnetic resonance cholangiopancreatography demonstrated 2.4 cm CBD dilation with heterogeneous intraductal material and no extrinsic mass effect. Two ERCP attempts using multiple accessories (raptor grasper, rat tooth, balloon extractor, stent retriever, mechanical lithotripter basket, in-stent balloon dilator, and biopsy forceps) failed to extract the partially fractured plastic stent. The patient developed hepatic biomarkers. A repeat ERCP 5 days later was performed using a rotatable pancreaticobiliary cholangioscope (1.7 mm channel), allowing passage of a 4.5 Fr large-caliber EHL probe. Electrohydraulic lithotripsy was applied to the stent and the surrounding area, which allowed loosening of the internally migrated, impacted stent and enabled it to float freely within the duct. Prior ERCP failures were likely due to a large, adherent stone encasing the stent, resembling a “lollipop” configuration. After CBD dilation, a 4 cm covered metal stent was placed to facilitate distal migration of the now-mobilized plastic stent. Using a combination of biopsy forceps and a raptor grasper, the partially fractured CBD plastic stent was successfully extracted from the distal duct. The patient tolerated the procedure without immediate complications and is scheduled for a follow-up ERCP in one month for metal stent removal. Discussion: We highlight the novel use of a large channel rotatable cholangioscope for stent retrieval. This case demonstrates the expanding role of advanced endoscopy in managing challenging pathology and emphasizes the critical need for structured follow-up regarding temporary stent management. Watch the video: https://tinyurl.com/25ACGS4169