Intraductal Radiofrequency Ablation Followed by the Stent-in-Stent Technique for the Removal of an Embedded, Intraductally Migrated Fully Covered Biliary Metal Stent: A Case Report

Fully covered self-expandable metal stents (FCSEMSs) are widely used in benign biliary strictures because they combine sustained radial force with the possibility of later endoscopic removal. When the stent stays in place for too long, tissue hyperplasia and intraductal migration can leave the stent firmly embedded in the duct wall. We report a 38-year-old woman with a Strasberg E2 bile duct injury after cholecystectomy and a benign segmental stricture of the common hepatic duct, treated with dilation, plastic biliary stents followed by a 10 mm × 6 cm FCSEMS. She was subsequently lost to follow-up for two and a half years and returned with mild abdominal pain and cholestasis. By then, the stent had migrated intraductally, with its distal end approximately 2 cm above the major papilla, and was impacted by granulation tissue. Conventional retrieval failed, as did a stent-in-stent attempt with a 10 mm × 8 cm FCSEMS. Cholangioscopy showed granulation tissue within the lumen and at the extremities of the impacted stent. Intraductal bipolar radiofrequency ablation (RFA) was applied at 9 W for 60 seconds along the entire length of the stent using a Habib EndoHPB catheter (Boston Scientific, Marlborough, MA, USA). Hyperplastic tissue was visibly reduced, but the stent could still not be extracted in the same session, so the stent-in-stent technique was repeated with a 10 mm × 8 cm FCSEMS and an 8.5 Fr × 12 cm plastic biliary stent. Finally, 49 days later, the embedded stent had mobilized toward the major papilla and was retrieved with foreign-body forceps. A small, low-output fistula of the mid common bile duct was identified on occlusion cholangiography. It was successfully managed with a further FCSEMS and a plastic stent. Sequential intraductal RFA followed by delayed stent-in-stent placement may serve as a rescue strategy when an embedded biliary FCSEMS is not removable by conventional means or by the stent-in-stent technique alone.