S5327 High-Power Argon Plasma Coagulation for Cutting Embedded Biliary Metal Stents in Ascending Cholangitis: A Life-Saving Endoscopic Strategy!

Introduction: When an uncovered (UMS) or partially covered metal stent (PCMS) becomes occluded and migrates deeply into the third portion of the duodenum, while remaining in the distal bile duct, removal and retrograde biliary access become nearly impossible. In such scenarios, trimming the stent to the level of the ampulla is a viable method to restore access. We present a fast and safe technique for cutting 2 biliary metal stents (in a stent-in-stent configuration) using high-power argon plasma coagulation (APC) with a forward-viewing gastroscope. Case Description: A 72-year-old man with subacute painless jaundice and a pancreatic head mass with liver metastases underwent initial ERCP with placement of an uncovered metal stent. Pathology confirmed lymphoma. A second ERCP placed a fully covered metal stent inside the original. The patient later developed ascending cholangitis due to obstruction and partial migration of both stents into the third portion of the duodenum. Proximal ends remained in the mid-bile duct, making removal and retrograde access impossible. High-power APC (80-100 W, 1.5 L/min gas flow) was used to trim the stents. The procedure took 25 minutes with no complications. Discussion: Managing complications caused by embedded or migrated UMS or PCMS—including cholangitis, duodenal bleeding, or perforation—is difficult, with few endoscopic options. High-power APC is a safe and efficient method to trim exposed metal stents, allowing for retrograde biliary access. This approach enables balloon sweeping and placement of plastic stents within the remaining metal stents, restoring patency and reducing the risk of further complications. High-setting APC (80-100 W, gas flow 0.8-1.5 L/min) is a fast, effective, and minimally invasive strategy for cutting obstructed, embedded, or migrated biliary metal stents. It provides life-saving access for managing ascending cholangitis and other complications. This widely available technique should be considered an essential tool in the therapeutic biliary endoscopist’s armamentarium.