G Model YDLD-2595; No. of Pages 4
ARTICLE IN PRESS Digestive and Liver Disease xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Short Report
Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique Andrea Tringali a,∗ , Daniel Blero b , Ivo Boˇskoski a , Pietro Familiari a , Vincenzo Perri a , Jacques Devière b , Guido Costamagna a a b
Digestive Endoscopy Unit, Catholic University, Rome, Italy Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
a r t i c l e
i n f o
Article history: Received 25 November 2013 Accepted 23 February 2014 Available online xxx Keywords: Benign biliary stricture Self Expandable Metal Stent Fully covered SEMS Ingrowth Overgrowth Stent migration
a b s t r a c t Background: Removal of biliary Fully Covered Self Expandable Metal Stents can fail due to stent migration and/or hyperplastic ingrowth/overgrowth. Methods: A case series of 5 patients with benign biliary strictures (2 post-cholecystectomy, 2 following liver transplantation and 1 related to chronic pancreatitis) is reported. The biliary stricture was treated by temporary insertion of Fully Covered Self Expandable Metal Stents. Stent removal failed due to proximal stent migration and/or overgrowth. Metal stent removal was attempted a few weeks after the insertion of another Fully Covered Metal Stent into the first one. Results: The inner Fully Covered Self Expandable Metal Stent compressed the hyperplastic tissue, leading to the extraction of both the stents in all cases. Two complications were reported as a result of the attempt to stents removal (mild pancreatitis and self-limited haemobilia). Conclusion: In the present series, the “SEMS in SEMS” technique revealed to be effective when difficulties are encountered during Fully Covered Self Expandable Metal Stents removal. © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
1. Introduction Fully Covered Self Expandable Metal Stents (FC-SEMS) are a promising and attractive alternative to plastic stents, and are becoming more widely used for the treatment of benign biliary strictures (BBS) [1–4]. The major advantage of FC-SEMS over multiple plastic stents, is the possibility to dilate a BBS with 2 procedures only (stent insertion and removal). The major concern of FC-SEMS in benign diseases is their removability. Safety and long-term efficacy of FC-SEMS for the treatment of BBS are under evaluation in clinical trials [5]. In published experiences, some cases of difficult or even impossible FC-SEMS removal are described [1]. Failure in FC-SEMS removal represents a serious problem in patients suffering from a benign disease. In fact, in case of irretrievable FC-SEMS even surgery can be impaired. A safe and reproducible technique to remove a FC-SEMS is advisable and the so
∗ Corresponding author at: Digestive Endoscopy Unit, Catholic University, Largo Agostino Gemelli 8, 00168 Rome, Italy. Tel.: +39 06 30156580; fax: +39 06 30156581. E-mail address: [email protected] (A. Tringali).
called “SEMS in SEMS” technique can be the solution, as previously described [6–8]. Five cases in which FC-SEMS removal was a challenge are described in the present series. 2. Case series 2.1. Case 1. Chronic pancreatitis related biliary stricture A 58-year-old man received a 4 cm long, 10 mm diameter, fully covered WallFlex stent (Boston Scientific, Natick Mass) to dilate a chronic pancreatitis-related BBS. Elective endoscopic retrograde cholangiopancreatography (ERCP), 11 months after placement, revealed a proximally migrated stent with the distal end resting right above the sphincterotomy (Supp. Figure S1). At cholangiography the stent was patent without clear signs of ingrowth with suspected hyperplastic overgrowth at the distal end. Removal with a rat-tooth forceps was attempted, but failed because the stent was distally impacted above the sphincterotomy (Fig. 1). A wire was passed alongside the stent and after 10 mm balloon dilation (Supp. Figure S2a) the stent regained its original shape due to the characteristics of the Nitinol meshes. Four 10 French plastic stents were inserted inside the Self Expandable Metal Stent (SEMS) to compress
http://dx.doi.org/10.1016/j.dld.2014.02.018 1590-8658/© 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
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Fig. 1. The retrieval loop of the WallFlex stent was grasped with a rat-tooth forceps (A). The stent deformed “like an accordion” (B).
the hyperplastic tissue and induce its ischaemia and necrosis (Supp. Figure S2b). After 2 months, the plastic stents were extracted, but a second attempt at FC-SEMS removal failed. Therefore, another 6 cm long, 10 mm diameter, fully covered WallFlex was inserted into the first one (Fig. 2). Two months later, a third attempt at FCSEMS removal succeeded using a rat-tooth forceps, and both the WallFlex stents were extracted (Fig. 3).
Fig. 2. A 6 cm long fully covered WallFlex stent is inserted into the 4 cm irretrievable stent.
2.2. Cases 2–3. Post-operative biliary stricture A 62-year-old lady developed a post-operative (PO) biliary stricture following open cholecystectomy. A 4 cm long, 10 mm diameter fully covered WallFlex was placed. Eleven months later, ERCP
Fig. 3. The 2 fully covered WallFlex stent after removal. The outer stent (A) appears damaged due to the repeated attempts at removal with intact covering. The inner stent (B) is intact after 2 months.
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
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Table 1 Patient and metal stent characteristics. Patient
Age/sex
BBS aetiology
1
58/M
CP
2
62/F
3
FC-SEMS diameter × length (mm)
Stenting period (months)
Causes of failed FC-SEMS removal
Techniques initially used for FC-SEMS removal
Inner FC-SEMS diameter × length (mm)
Time for both FC-SEMS removal (days)a
10 × 40
11
Multiple plastic stents
10 × 60
60
PO
10 × 40
11
Intrabiliary migration + distal overgrowth Intrabiliary migration + proximal overgrowth
10 × 60
30
51/F
PO
10 × 60
11
Proximal overgrowth
10 × 60
15
4
62/M
OLT
10 × 80
12
10 × 80
13
5
69/M
OLT
10 × 80
6
Intrabiliary migration + distal overgrowth Intrabiliary migration + distal overgrowth
Balloon dilation and Multiple plastic stents Balloon dilation –
–
10 × 60
25
M, male; F, female; BBS, benign biliary strictures; FC-SEMS, Fully Covered Self Expandable Metal Stents; CP, chronic pancreatitis; PO, post-operative; OLT, biliary stricture following orthotopic liver transplantation. a Days from second FC-SEMS insertion.
showed a proximal migration of the stent and proximal overgrowth. Balloon dilation (12 mm) of the papilla and of the proximal overgrowth was attempted, but SEMS removal with rat-tooth forceps failed. Four plastic stents were inserted inside the FC-SEMS, as described in the previous case. ERCP was complicated by mild pancreatitis which resolved in 6 days. Six weeks later the plastic stents were extracted but FC-SEMS removal failed again and a 6 cm long, 10 mm diameter, FC-SEMS (NITI-S, Teawoong Medical, South Korea) was inserted into the previous one. One month later, removal of both the SEMS was possible due to the compressive effect of the inner stent on the tissue overgrowth. A 51-year-old female with PO biliary stricture occurred after laparoscopic cholecystectomy, underwent ERCP with placement of a 6 cm long, 10 mm diameter fully covered WallFlex to dilate the stricture. Ten months later scheduled SEMS removal failed. At cholangiography the SEMS was patent, without clear evidence of ingrowth. However, when the stent retrieval loop was grasped and pulled with a rat-tooth forceps, the retrieval loop snapped and the proximal end of the stent remained fixed at the level of the stricture, more likely because of hyperplastic overgrowth. A 10 mm dilation balloon was inflated inside the FC-SEMS at the level of its proximal end, but stent removal failed again. Another 6 cm long, 10 mm diameter, fully covered WallFlex was inserted into the first one. Two weeks later both the FC-SEMS were successfully extracted with a foreign body forceps. 2.3. Cases 4–5. Biliary stricture after orthotopic liver transplantation A 62-year-old male underwent orthotopic liver transplantation (OLT) for hepatocarcinoma in the setting of alcoholic cirrhosis. One month after OLT, the patient developed a stricture of the biliary anastomosis, which was treated with an 8 cm long, 10 mm diameter, fully covered WallFlex for 12 months. FC-SEMS removal failed due to proximal migration associated with distal overgrowth. Therefore, a second fully covered, 8 cm long, 10 mm diameter, WallFlex was inserted into the previous one. After 2 weeks both the stents were easily retrieved without complications. A 69-year-old male underwent OLT for HCV-related liver cirrhosis. Following OLT the patient had HCV infection recurrence. One year later the patient had cholangitis and a dominant ischaemic stricture of the common hepatic duct (within 2 cm from the main hepatic confluence) was diagnosed by magnetic resonance
cholangiography, and treated with repeated insertion of multiple 10 French plastic stents (up to 8), over 5 procedures, in 20 months. The patient had stricture recurrence and cholangitis 1 year after plastic stents removal. Features of the biliary stricture were unchanged and an 8 cm long, 10 mm diameter, fully covered WallFlex was inserted for an additional attempt at stricture dilation. Six months later, planned SEMS removal failed due to proximal stent migration with distal overgrowth. A fully covered 6 cm long, 10 mm diameter, FC-SEMS (Niti-S, Taewoong) was inserted in order to compress the distal overgrowth and facilitate subsequent removal. Three weeks later, both SEMS were extracted with a foreign body forceps with the occurrence of self-limited haemobilia. 3. Discussion FC-SEMS are a promising alternative to plastic stents for the endoscopic management of BBS and their use is still suggested in the setting of prospective studies [9]. Three of the reported cases were treated in a multicentre trial [5] where stent removability was the primary endpoint. The fourth and fifth cases were treated out of protocol in tertiary referral centres. The “SEMS in SEMS” technique had already been successfully applied to remove uncovered [6,7] and fully covered [8] biliary SEMS mistakenly inserted due to suspected malignancy. In the present case series FC-SEMS were used in BBS. Usually, FCSEMS removal is relatively easy. However in case of proximal stent migration associated with ingrowth/overgrowth, FC-SEMS removal become challenging. In our series there was no cholangiographic evidence of hyperplastic tissue ingrowth, as a result of metal stents covering. Nevertheless we observed in all the cases the presence of tissue overgrowth limited to the distal or proximal end of the metal stent, as a possible result of an encasement of the metal wires at the stent ends. Intrabiliary migration resulted the main problem affecting FC-SEMS removability (4/5 cases) in our experience. According to our experience, when removing an FC-SEMS, it is advisable to follow 2 steps before grasping and pulling with forceps or a snare: (1) perform a cholangiography to assess stent patency and rule out possible ingrowth; (2) rule out overgrowth/wires encasement by inflating and pulling with a Fogarty balloon; if the stent can be mobilized after balloon sweep, then removal is feasible. When the distal end of the stent has migrated inside the common
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
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bile duct and is not visible anymore through the papilla, grasping the stent and pulling with forceps can lead to difficult situations as shown in Fig. 2. Furthermore, balloon dilation and multiple plastic stenting in such situations, at least in our series, resulted ineffective. The insertion of a second and possibly longer FC-SEMS for a short period of time (14–28 days) leads to removal of the first stent in all the reported cases. In the last case, a shorter stent was used instead. In such a case, where the proximal end of the first stent was immediately below the main biliary confluence, the placement of a longer stent could cause the occlusion of the main hepatic confluence and lead to cholangitis. The described technique reproduces a previously described method [10] in the setting of benign oesophageal diseases, where a self expanding plastic stent (Polyflex, Boston Scientific) was used to remove oesophageal SEMS by compression of hyperplastic tissue ingrowth. In 2 of the 5 cases, two different models of FC-SEMS were used on the same patient, without difficulty. Thus, the use of the same brand of stent does not seem mandatory, more important seems to be the use of the same stent diameter. The “SEMS in SEMS” technique is safe, and allowed, in our series, the removal of biliary FC-SEMS involved by overgrowth/metal wires encasement or proximal migration. According to our and previously published experience [6–8], both SEMS removal should be attempted within 4 weeks from the inner FC-SEMS insertion (Table 1). Conflict of interest statement A. Tringali had a financial relationship with Boston Scientific (one day animal lab in 2012 and 2013). J. Devière has a financial relationship with Boston Scientific (departmental research support). G. Costamagna has a financial relationship with Boston Scientific and Taewoong Medical (advisory committees or review panels, speaking and teaching). D. Blero, I. Boˇskoski, P. Familiari and V. Perri
have no financial relationship with a commercial entity producing health-care related products and/or services relevant to this article. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.dld.2014.02.018. References [1] Cahen DL, Rauws EA, Gouma DJ, et al. Removable fully covered self-expandable metal stents in the treatment of common bile duct strictures due to chronic pancreatitis: a case series. Endoscopy 2008;40:697–700. [2] Mahajan A, Ho H, Sauer B, et al. Temporary placement of fully covered selfexpandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc 2009;70:303–9. [3] Poley JW, Cahen DL, Metselaar HJ, et al. A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video). Gastrointest Endosc 2012;75:783–9. [4] Tarantino I, Mangiavillano B, Di Mitri R, et al. Fully covered self-expandable metallic stents in benign biliary strictures: a multicenter study on efficacy and safety. Endoscopy 2012;44:923–7. [5] Deviere J, Reddy DN, Puspok A, et al. Preliminary results from a 187 patient multicenter prospective trial using metal stents for treatment of benign biliary strictures. Gastrointest Endosc 2012;4S:AB123. [6] Arias Dachary FJ, Chioccioli C, Deprez PH. Application of the coveredstent-in-uncovered-stent technique for easy and safe removal of embedded biliary uncovered SEMS with tissue ingrowth. Endoscopy 2010;42: E304–5. [7] Tan DM, Lillemoe KD, Fogel EL. A new technique for endoscopic removal of uncovered biliary self-expandable metal stents: stent-in-stent technique with a fully covered biliary stent. Gastrointest Endosc 2012;75:923–5. [8] Menon S. Removal of an embedded covered biliary stent by the stent-in-stent technique. World J Gastroenterol 2013;19:6108–9. [9] Dumonceau JM, Tringali A, Blero D, et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012;44:277–98. [10] Evrard S, Le Moine O, Lazaraki G, et al. Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc 2004;60:894–900.
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
ARTICLE IN PRESS Digestive and Liver Disease xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Short Report
Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique Andrea Tringali a,∗ , Daniel Blero b , Ivo Boˇskoski a , Pietro Familiari a , Vincenzo Perri a , Jacques Devière b , Guido Costamagna a a b
Digestive Endoscopy Unit, Catholic University, Rome, Italy Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
a r t i c l e
i n f o
Article history: Received 25 November 2013 Accepted 23 February 2014 Available online xxx Keywords: Benign biliary stricture Self Expandable Metal Stent Fully covered SEMS Ingrowth Overgrowth Stent migration
a b s t r a c t Background: Removal of biliary Fully Covered Self Expandable Metal Stents can fail due to stent migration and/or hyperplastic ingrowth/overgrowth. Methods: A case series of 5 patients with benign biliary strictures (2 post-cholecystectomy, 2 following liver transplantation and 1 related to chronic pancreatitis) is reported. The biliary stricture was treated by temporary insertion of Fully Covered Self Expandable Metal Stents. Stent removal failed due to proximal stent migration and/or overgrowth. Metal stent removal was attempted a few weeks after the insertion of another Fully Covered Metal Stent into the first one. Results: The inner Fully Covered Self Expandable Metal Stent compressed the hyperplastic tissue, leading to the extraction of both the stents in all cases. Two complications were reported as a result of the attempt to stents removal (mild pancreatitis and self-limited haemobilia). Conclusion: In the present series, the “SEMS in SEMS” technique revealed to be effective when difficulties are encountered during Fully Covered Self Expandable Metal Stents removal. © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
1. Introduction Fully Covered Self Expandable Metal Stents (FC-SEMS) are a promising and attractive alternative to plastic stents, and are becoming more widely used for the treatment of benign biliary strictures (BBS) [1–4]. The major advantage of FC-SEMS over multiple plastic stents, is the possibility to dilate a BBS with 2 procedures only (stent insertion and removal). The major concern of FC-SEMS in benign diseases is their removability. Safety and long-term efficacy of FC-SEMS for the treatment of BBS are under evaluation in clinical trials [5]. In published experiences, some cases of difficult or even impossible FC-SEMS removal are described [1]. Failure in FC-SEMS removal represents a serious problem in patients suffering from a benign disease. In fact, in case of irretrievable FC-SEMS even surgery can be impaired. A safe and reproducible technique to remove a FC-SEMS is advisable and the so
∗ Corresponding author at: Digestive Endoscopy Unit, Catholic University, Largo Agostino Gemelli 8, 00168 Rome, Italy. Tel.: +39 06 30156580; fax: +39 06 30156581. E-mail address: [email protected] (A. Tringali).
called “SEMS in SEMS” technique can be the solution, as previously described [6–8]. Five cases in which FC-SEMS removal was a challenge are described in the present series. 2. Case series 2.1. Case 1. Chronic pancreatitis related biliary stricture A 58-year-old man received a 4 cm long, 10 mm diameter, fully covered WallFlex stent (Boston Scientific, Natick Mass) to dilate a chronic pancreatitis-related BBS. Elective endoscopic retrograde cholangiopancreatography (ERCP), 11 months after placement, revealed a proximally migrated stent with the distal end resting right above the sphincterotomy (Supp. Figure S1). At cholangiography the stent was patent without clear signs of ingrowth with suspected hyperplastic overgrowth at the distal end. Removal with a rat-tooth forceps was attempted, but failed because the stent was distally impacted above the sphincterotomy (Fig. 1). A wire was passed alongside the stent and after 10 mm balloon dilation (Supp. Figure S2a) the stent regained its original shape due to the characteristics of the Nitinol meshes. Four 10 French plastic stents were inserted inside the Self Expandable Metal Stent (SEMS) to compress
http://dx.doi.org/10.1016/j.dld.2014.02.018 1590-8658/© 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
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Fig. 1. The retrieval loop of the WallFlex stent was grasped with a rat-tooth forceps (A). The stent deformed “like an accordion” (B).
the hyperplastic tissue and induce its ischaemia and necrosis (Supp. Figure S2b). After 2 months, the plastic stents were extracted, but a second attempt at FC-SEMS removal failed. Therefore, another 6 cm long, 10 mm diameter, fully covered WallFlex was inserted into the first one (Fig. 2). Two months later, a third attempt at FCSEMS removal succeeded using a rat-tooth forceps, and both the WallFlex stents were extracted (Fig. 3).
Fig. 2. A 6 cm long fully covered WallFlex stent is inserted into the 4 cm irretrievable stent.
2.2. Cases 2–3. Post-operative biliary stricture A 62-year-old lady developed a post-operative (PO) biliary stricture following open cholecystectomy. A 4 cm long, 10 mm diameter fully covered WallFlex was placed. Eleven months later, ERCP
Fig. 3. The 2 fully covered WallFlex stent after removal. The outer stent (A) appears damaged due to the repeated attempts at removal with intact covering. The inner stent (B) is intact after 2 months.
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
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3
Table 1 Patient and metal stent characteristics. Patient
Age/sex
BBS aetiology
1
58/M
CP
2
62/F
3
FC-SEMS diameter × length (mm)
Stenting period (months)
Causes of failed FC-SEMS removal
Techniques initially used for FC-SEMS removal
Inner FC-SEMS diameter × length (mm)
Time for both FC-SEMS removal (days)a
10 × 40
11
Multiple plastic stents
10 × 60
60
PO
10 × 40
11
Intrabiliary migration + distal overgrowth Intrabiliary migration + proximal overgrowth
10 × 60
30
51/F
PO
10 × 60
11
Proximal overgrowth
10 × 60
15
4
62/M
OLT
10 × 80
12
10 × 80
13
5
69/M
OLT
10 × 80
6
Intrabiliary migration + distal overgrowth Intrabiliary migration + distal overgrowth
Balloon dilation and Multiple plastic stents Balloon dilation –
–
10 × 60
25
M, male; F, female; BBS, benign biliary strictures; FC-SEMS, Fully Covered Self Expandable Metal Stents; CP, chronic pancreatitis; PO, post-operative; OLT, biliary stricture following orthotopic liver transplantation. a Days from second FC-SEMS insertion.
showed a proximal migration of the stent and proximal overgrowth. Balloon dilation (12 mm) of the papilla and of the proximal overgrowth was attempted, but SEMS removal with rat-tooth forceps failed. Four plastic stents were inserted inside the FC-SEMS, as described in the previous case. ERCP was complicated by mild pancreatitis which resolved in 6 days. Six weeks later the plastic stents were extracted but FC-SEMS removal failed again and a 6 cm long, 10 mm diameter, FC-SEMS (NITI-S, Teawoong Medical, South Korea) was inserted into the previous one. One month later, removal of both the SEMS was possible due to the compressive effect of the inner stent on the tissue overgrowth. A 51-year-old female with PO biliary stricture occurred after laparoscopic cholecystectomy, underwent ERCP with placement of a 6 cm long, 10 mm diameter fully covered WallFlex to dilate the stricture. Ten months later scheduled SEMS removal failed. At cholangiography the SEMS was patent, without clear evidence of ingrowth. However, when the stent retrieval loop was grasped and pulled with a rat-tooth forceps, the retrieval loop snapped and the proximal end of the stent remained fixed at the level of the stricture, more likely because of hyperplastic overgrowth. A 10 mm dilation balloon was inflated inside the FC-SEMS at the level of its proximal end, but stent removal failed again. Another 6 cm long, 10 mm diameter, fully covered WallFlex was inserted into the first one. Two weeks later both the FC-SEMS were successfully extracted with a foreign body forceps. 2.3. Cases 4–5. Biliary stricture after orthotopic liver transplantation A 62-year-old male underwent orthotopic liver transplantation (OLT) for hepatocarcinoma in the setting of alcoholic cirrhosis. One month after OLT, the patient developed a stricture of the biliary anastomosis, which was treated with an 8 cm long, 10 mm diameter, fully covered WallFlex for 12 months. FC-SEMS removal failed due to proximal migration associated with distal overgrowth. Therefore, a second fully covered, 8 cm long, 10 mm diameter, WallFlex was inserted into the previous one. After 2 weeks both the stents were easily retrieved without complications. A 69-year-old male underwent OLT for HCV-related liver cirrhosis. Following OLT the patient had HCV infection recurrence. One year later the patient had cholangitis and a dominant ischaemic stricture of the common hepatic duct (within 2 cm from the main hepatic confluence) was diagnosed by magnetic resonance
cholangiography, and treated with repeated insertion of multiple 10 French plastic stents (up to 8), over 5 procedures, in 20 months. The patient had stricture recurrence and cholangitis 1 year after plastic stents removal. Features of the biliary stricture were unchanged and an 8 cm long, 10 mm diameter, fully covered WallFlex was inserted for an additional attempt at stricture dilation. Six months later, planned SEMS removal failed due to proximal stent migration with distal overgrowth. A fully covered 6 cm long, 10 mm diameter, FC-SEMS (Niti-S, Taewoong) was inserted in order to compress the distal overgrowth and facilitate subsequent removal. Three weeks later, both SEMS were extracted with a foreign body forceps with the occurrence of self-limited haemobilia. 3. Discussion FC-SEMS are a promising alternative to plastic stents for the endoscopic management of BBS and their use is still suggested in the setting of prospective studies [9]. Three of the reported cases were treated in a multicentre trial [5] where stent removability was the primary endpoint. The fourth and fifth cases were treated out of protocol in tertiary referral centres. The “SEMS in SEMS” technique had already been successfully applied to remove uncovered [6,7] and fully covered [8] biliary SEMS mistakenly inserted due to suspected malignancy. In the present case series FC-SEMS were used in BBS. Usually, FCSEMS removal is relatively easy. However in case of proximal stent migration associated with ingrowth/overgrowth, FC-SEMS removal become challenging. In our series there was no cholangiographic evidence of hyperplastic tissue ingrowth, as a result of metal stents covering. Nevertheless we observed in all the cases the presence of tissue overgrowth limited to the distal or proximal end of the metal stent, as a possible result of an encasement of the metal wires at the stent ends. Intrabiliary migration resulted the main problem affecting FC-SEMS removability (4/5 cases) in our experience. According to our experience, when removing an FC-SEMS, it is advisable to follow 2 steps before grasping and pulling with forceps or a snare: (1) perform a cholangiography to assess stent patency and rule out possible ingrowth; (2) rule out overgrowth/wires encasement by inflating and pulling with a Fogarty balloon; if the stent can be mobilized after balloon sweep, then removal is feasible. When the distal end of the stent has migrated inside the common
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
G Model YDLD-2595; No. of Pages 4
ARTICLE IN PRESS
4
A. Tringali et al. / Digestive and Liver Disease xxx (2014) xxx–xxx
bile duct and is not visible anymore through the papilla, grasping the stent and pulling with forceps can lead to difficult situations as shown in Fig. 2. Furthermore, balloon dilation and multiple plastic stenting in such situations, at least in our series, resulted ineffective. The insertion of a second and possibly longer FC-SEMS for a short period of time (14–28 days) leads to removal of the first stent in all the reported cases. In the last case, a shorter stent was used instead. In such a case, where the proximal end of the first stent was immediately below the main biliary confluence, the placement of a longer stent could cause the occlusion of the main hepatic confluence and lead to cholangitis. The described technique reproduces a previously described method [10] in the setting of benign oesophageal diseases, where a self expanding plastic stent (Polyflex, Boston Scientific) was used to remove oesophageal SEMS by compression of hyperplastic tissue ingrowth. In 2 of the 5 cases, two different models of FC-SEMS were used on the same patient, without difficulty. Thus, the use of the same brand of stent does not seem mandatory, more important seems to be the use of the same stent diameter. The “SEMS in SEMS” technique is safe, and allowed, in our series, the removal of biliary FC-SEMS involved by overgrowth/metal wires encasement or proximal migration. According to our and previously published experience [6–8], both SEMS removal should be attempted within 4 weeks from the inner FC-SEMS insertion (Table 1). Conflict of interest statement A. Tringali had a financial relationship with Boston Scientific (one day animal lab in 2012 and 2013). J. Devière has a financial relationship with Boston Scientific (departmental research support). G. Costamagna has a financial relationship with Boston Scientific and Taewoong Medical (advisory committees or review panels, speaking and teaching). D. Blero, I. Boˇskoski, P. Familiari and V. Perri
have no financial relationship with a commercial entity producing health-care related products and/or services relevant to this article. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.dld.2014.02.018. References [1] Cahen DL, Rauws EA, Gouma DJ, et al. Removable fully covered self-expandable metal stents in the treatment of common bile duct strictures due to chronic pancreatitis: a case series. Endoscopy 2008;40:697–700. [2] Mahajan A, Ho H, Sauer B, et al. Temporary placement of fully covered selfexpandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc 2009;70:303–9. [3] Poley JW, Cahen DL, Metselaar HJ, et al. A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video). Gastrointest Endosc 2012;75:783–9. [4] Tarantino I, Mangiavillano B, Di Mitri R, et al. Fully covered self-expandable metallic stents in benign biliary strictures: a multicenter study on efficacy and safety. Endoscopy 2012;44:923–7. [5] Deviere J, Reddy DN, Puspok A, et al. Preliminary results from a 187 patient multicenter prospective trial using metal stents for treatment of benign biliary strictures. Gastrointest Endosc 2012;4S:AB123. [6] Arias Dachary FJ, Chioccioli C, Deprez PH. Application of the coveredstent-in-uncovered-stent technique for easy and safe removal of embedded biliary uncovered SEMS with tissue ingrowth. Endoscopy 2010;42: E304–5. [7] Tan DM, Lillemoe KD, Fogel EL. A new technique for endoscopic removal of uncovered biliary self-expandable metal stents: stent-in-stent technique with a fully covered biliary stent. Gastrointest Endosc 2012;75:923–5. [8] Menon S. Removal of an embedded covered biliary stent by the stent-in-stent technique. World J Gastroenterol 2013;19:6108–9. [9] Dumonceau JM, Tringali A, Blero D, et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012;44:277–98. [10] Evrard S, Le Moine O, Lazaraki G, et al. Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc 2004;60:894–900.
Please cite this article in press as: Tringali A, et al. Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.02.018
