The patient had undergone cholecystectomy for calculous gallbladder disease, followed by ERCP with biliary stent placement. He was referred for endoscopic removal of a proximally migrated biliary stent. Scout film obtained at the time of ERCP showed a 10-French plastic biliary stent predominantly within the left intrahepatic biliary tree. Attempts at wire-guided cannulation of the stent using fluoroscopy alone were unsuccessful. We therefore elected to pass the cholangioscope through the duodenoscope in order to obtain direct utilization of the stent. With the bifurcation seen in the distance, the scope was slowly withdrawn and identified the distal portion of the stent within the proximal common hepatic duct. On this view, the end of the stent appears occluded with sludge and debris. Subsequent attempts to pass a long 0.035 inch hydrophilic guidewire into the lumen of the stent were unsuccessful, as seen here, due to presence of this sludge and debris. A cholangioscopic biopsy forceps was then passed through the working channel of the scope and used to gently debride and tunnel through this debris in order to create a tract for wire passage. This was performed cautiously so as to avoid further proximal migration of the stent. Once a tunnel had been established, the guidewire could now be easily passed into the lumen of the stent. This was confirmed by fluoroscopy. Using a Soehendra stent retrieval device, the stent was withdrawn to the level of the ampulla, and the stent was then grasped with a rat-tooth forceps and extracted completely from the patient. The intact stent is visualized here. Occlusion cholangiogram performed following stent extraction revealed a normal post cholecystectomy cholangiogram. There are multiple endoscopic techniques for extraction of proximally migrated biliary stents. The ability to cannulate the stent with a wire permits use of a Soehendra type stent retrieval device. This case demonstrates how cholangioscope-assisted wire cannulation may assist in retrieval of a proximally migrated occluded biliary stent.
Patrick Yachimski, MD, Vanderbilt University Medical Center