Lawrence J. Brandt, MD, Associate Editor for Focal Points. A rare complication with ... Hiroshi Kawakami, MD, PhD, Minoru Uebayashi, MD,. PhD, Kohei Konishi ...
AT THE FOCAL POINT Lawrence J. Brandt, MD, Associate Editor for Focal Points
A rare complication with extraction of proximally migrated biliary stent by using a basket catheter
A 70-year-old man with jaundice was admitted to our hospital for further examination. CT revealed a low-density mass in the pancreatic head (A, left, arrows), and dilatation
of the common bile duct and the pancreatic duct. Definite diagnosis of pancreatic adenocarcinoma was made by EUS-FNA of the mass. Duodenoscopy revealed an exophytic
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At the Focal Point
mass involving the ampulla of Vater (A, right). ERCP revealed interruption of the lower bile duct (B, left), and endoscopic biliary drainage (EBD) was performed by placement of a 7F stent. Abnormal laboratory data normalized immediately after EBD. Four days after EBD, the patient developed cholangitis. Subsequent ERCP revealed that the stent had migrated proximally above the stricture (B, middle). By grasping the distal end of the stent with a retrieval basket catheter (B, right), we were able to remove the stent; however, duodenoscopy showed local trauma of the ampulla of Vater (C) with oozing. Immediately after stent retrieval, a nasobiliary drainage tube was placed endoscopically to ensure continued drainage. A piece of tissue was found stuck to the torn ampulla of Vater (D, left), microscopic examination of which revealed that the adenocarcinoma had invaded the duodenal muscular layer (D,
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right). Two weeks after stent retrieval, a metallic stent was placed without complication. DISCLOSURE The authors report that there are no disclosures relevant to this publication. Hiroshi Kawakami, MD, PhD, Minoru Uebayashi, MD, PhD, Kohei Konishi, MD, PhD, Masaki Kuwatani, MD, PhD, Keisuke Shinada, MD, Hiroaki Yamato, MD, Masahiro Asaka, MD, PhD, Department of Gastroenterology, Hokkaido University, Graduate School of Medicine, Sapporo, Japan doi:10.1016/j.gie.2007.12.008
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Commentary Migration of biliary stents occurs in up to about 6% of cases, and proximal migration is more common than distal migration. Such migration obviously is not desirable and, as in this case, when proximal, can precipitate cholangitis. As for the damage sustained to the ampulla, the invasive carcinoma is probably more responsible than the endoscopist. Extracellular matrix, including the interstitial matrix and the basement membrane, serves many functions, one of which is anchorage of cells. Metastasis, however, often destroys the extracellular matrix, thereby reducing tissue integrity. The architect William Buckminster Fuller once said, ‘‘Integrity is the essence of everything successful.’’ He was referring to a behavioral personality trait, but his statement also has relevance to the behavior of our tissues. Lawrence J. Brandt, MD Associate Editor for Focal Points
Cholesterolosis of the common bile duct with anomalous arrangement of the pancreaticobiliary ductal system
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