Rescue technique using a diathermic dilator for an unremovable stent in malignant perihilar biliary obstruction.

Endoscopic biliary stenting is a useful and safe technique for malignant biliary obstructions. A plastic stent is frequently used because of its low cost and ease of deployment. However, it is occasionally difficult to remove a plastic stent because of severe stricture. We describe a rescue technique for immovable plastic stents, using a diathermic dilator in a case of perihilar biliary obstruction. A 63-year-old woman with jaundice due to hilar biliary obstruction was referred to our hospital. A diagnosis of gallbladder cancer was made from findings of a thickened gallbladder wall and massive ascites revealed by computed tomography (▶Fig. 1) and magnetic resonance cholangiopancreatography (▶Fig. 2). For biliary decompression and pathological confirmation, endoscopic retrograde cholangiography (ERC) was performed, and a 7-Fr plastic stent was placed (▶Fig. 3, ▶Video1). The patient underwent a second ERC 4 days later because of elevated biliary enzymes. The plastic stent could not be removed using forceps and snares, and the torn-off stent was left in place (▶Fig. 4). Although needle-knife sphincterotomy was performed to expose the residual plastic stent, the stent could not be grasped. A 0.025-inch guidewire could be advanced alongside the plastic stent, but a sphincterotome (CleverCut 3V; Olympus, Tokyo, Japan) could not. Successful dilation of the perihilar biliary stricture was achieved by advancing a 6-Fr wire-guided diathermic dilator (Cysto-Gastro-Set; Endo-Flex GmbH, Voerde, Germany) (▶Fig. 5). However, the remaining plastic stent also migrated. Thus, a 10-mm lumen partially covered, self-expandable, metallic stent (WallFlex biliary stent; Boston Scientific Japan, Tokyo, Japan) was deployed alongside the plastic stent (▶Fig. 6). In cases of malignant biliary stricture, removal of a plastic stent is time-consuming and might cause complications. The VIDEO 1