LAUSR

A 52-year-old woman with benign perihilar left intrahepatic duct stricture underwent repeated stricture dilation and multiple plastic stent placements. Subsequently, an 8mm×12 cm multihole fully covered self-expanding metal stent (MH-FCSEMS) was inserted. Six months later, she had abnormal liver biochemistry. Endoscopic retrograde cholangiography (ERC) revealed supra-papillary stent migration and tissue ingrowth at the proximal end (▶Fig. 1). Cholangioscopy (SpyGlass System; Boston Scientific Corp., Marlborough, Massachusetts, USA) showed that the stent lumen was obliterated by stone cast (▶Fig. 2). Stent removal with forceps and snare failed. The patient was referred to our center for a second opinion. ERC and cholangioscopy were performed. The distal end of the stent had collapsed with stone obstruction, which precluded guidewire passage. We failed to pull the stent out with a polypectomy snare. With the stent still trapped by the snare, the snare was transected near the handle. The plastic sheath of the snare and the duodenoscope were removed simultaneously. The metal sheath of a mechanical lithotripter (Olympus, Tokyo, Japan) was advanced over the snare wire, which was then connected to the lithotripter handle. The first attempt to pull the metal stent into the sheath by rotating the handle failed as the snare wire detached from the stent. At the second attempt, the snare grasped the more proximal portion of the stent. The metal stent was successfully pulled into the metal sheath and removed (▶Fig. 3, ▶Video 1). A 10 Fr ×12 cm plastic stent was inserted temporarily. The patient was discharged the next day with improved liver biochemistry. Different techniques for removal of selfexpanding metal stent (SEMS) have been described, including invagination/inversion [1], “SEMS-in-SEMS” [2, 3], and “guidewire and mechanical lithotripter” [4, 5]. However, these methods could not be applied in our patient due to stent obstruction and supra-papillary migration. We demonstrated that the “snare and lithotripter” technique is an effective method of SEMS removal in these situations. Video 1 Removal of migrated and embedded multi-hole fully covered self-expanding metal stent using “snare and lithotripter” technique. ▶ Fig. 1 Endoscopic retrograde cholangiography revealed supra-papillary stent migration (white arrow) and tissue ingrowth at the proximal end (red arrowheads).