D0189 - Use of Loop Cutter to Successfully Retrieve a Forceps Stuck in a Self-Expandable Metal Biliary Stent

Tuesday, October 25, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

JK

Jacyln E. Kagihara, MD

George Washington University
Washington, DC

Jaclyn E. Kagihara, MD, Marie L. Borum, MD, EdD, MPH, Waseem Aziz, MD
George Washington University, Washington, DC

Introduction: Self-expanding metal stents (SEMS) occasionally migrate, and subsequent endoscopic retrieval may be technically challenging. A variety of techniques using basket, balloon, snares, and forceps have been described, but there are few reports on salvage techniques for when these attempts go awry. We describe the first-ever successful retrieval of forceps stuck in a SEMS by cutting the wire of the stent with a loop cutter.

Case Description/Methods: A 39-year-old man with metastatic pancreatic cancer who had undergone chemoradiation was admitted to our hospital for obstructive jaundice due to stent migration and occlusion. His initial endoscopic retrograde pancreatography (ERCP) for obstructive jaundice due to malignant stricture was performed at an outside facility and records were not available. Physical exam was notable for cachexia, jaundice, and epigastric tenderness. Labs showed mild leukocytosis and cholestatic hyperbilirubinemia (Table 1). Computed tomography (CT) showed narrowing of the distal common bile duct (CBD) stent, concerning tumor ingrowth of the residual pancreatic head (Figure 1A). A decision was made to perform SEMS exchange. Duodenoscopy revealed fully covered SEMS with distal migration from the CBD (Fig. 1B), successfully removed with a 10-millimeter alligator and rat tooth forceps. This revealed another SEMS extending from the papilla with apparent occlusion (Fig. 1C). While attempting to remove this SEMS, the wire of one of the cells of the SEMS became trapped in the hinge of the forceps and despite multiple maneuvers was unable to be removed. The forceps was then cut at the handle and the duodenoscope was removed, leaving the forceps impacted in the partially covered SEMS in place. A dual channel endoscope was reinserted along with the forceps. Jumbo forceps as well as scissor forceps were tried, but were unsuccessful in removing the alligator and rat tooth forceps. A loop cutter was then used to cut the SEMS wire, allowing its release from the hinge of the forceps. The forceps was retrieved, and the dual channel endoscope was exchanged for the duodenoscope to allow for insertion of a new fully covered SEMS within the impacted partially covered SEMS (Fig. 1D-E).

Discussion: Laser-cut SEMS have an open cell structure which forceps may get stuck on. Argon plasma coagulation is a useful procedure for cutting a SEMS. While jumbo forceps and scissor forceps were unsuccessful in this case, loop cutter may be a novel and effective technique in these difficult situations.

Figure: Figure 1. A, CT of the abdomen shows CBD with pneumobilia and narrowing of the distal portion of the stent with adjacent metallic material concerning for residual tumor compression. B, Previously placed fully covered SEMS migrated distally. C, Removal of the fully covered SEMS reveals another previously placed occluded SEMS that became stuck on alligator and rat tooth forceps during attempted removal. D, Wire cannulation of the CBD. E, Placement of a new fully covered SEMS inserted within the previously placed impacted SEMS.

Serologies	24 Days Prior to ERCP	Day of ERCP	7 Days After ERCP	Normal Values
White blood cell count (K/μL)	2.05	13.97	12.02	4.80-10.80
Hemoglobin (g/dL)	9.6	8.4	7.8	14.0-18.0
Platelet count (K/μL)	201	484	531	130-400
Bilirubin, total (mg/dL)	1.3	11.1	5.8	0.2-1.3
Bilirubin, direct (mg/dL)	0.0	5.1	1.0	0.0-0.3
Bilirubin, indirect (mg/dL)	0.7	2.0	1.2	0.0-1.1
Alkaline phosphatase (U/L)	956	1490	1431	40-125
Aspartate aminotransferase (U/L)	36	139	98	10-45
Alanine aminotransferase (U/L)	18	56	50	10-45
Albumin (g/dL)	2.4	3.0	2.7	3.5-5.0

Table: Table 1. Laboratory Data

Disclosures:

Jaclyn Kagihara indicated no relevant financial relationships.

Marie Borum: Takeda – Advisory Committee/Board Member.

Waseem Aziz indicated no relevant financial relationships.

Jaclyn E. Kagihara, MD, Marie L. Borum, MD, EdD, MPH, Waseem Aziz, MD. D0189 - Use of Loop Cutter to Successfully Retrieve a Forceps Stuck in a Self-Expandable Metal Biliary Stent, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.