What is the management of stent migration in Endoscopic Ultrasonography (EUS) guided choledochoduodenostomy?

From the Guidelines

To manage stent migration in EUS-guided choledochoduodenostomy, prompt intervention with endoscopic repositioning or placement of a new stent is essential, prioritizing the use of dedicated lumen-apposing metal stents (LAMS) with anti-migration features, as supported by recent clinical practice updates 1.

Key Considerations

• Confirm stent migration with imaging (CT or fluoroscopy) to determine the stent's location 1.
• For partially migrated stents, attempt endoscopic repositioning using rat-tooth forceps, snares, or retrieval balloons.
• If the stent has completely migrated inward, consider placing a new stent through the existing tract while leaving the migrated stent in place if it's not causing complications.
• For outward migration, a new stent placement is necessary.

Prevention Strategies

• Use dedicated LAMS like AXIOS (15mm × 10mm) or HOT AXIOS systems which have anti-migration features 1.
• Alternatively, use fully covered self-expandable metal stents (FCSEMS) with anchoring mechanisms such as flared ends.
• Ensure proper stent deployment with at least 1cm of the stent inside the bile duct and confirm position under fluoroscopic guidance.

Post-Procedure Care

• Limit patient activity for 24-48 hours.
• Schedule follow-up imaging within 1-2 weeks to monitor for potential complications, as adverse events occur in 4.8% to 22% of cases, including bleeding, recurrent cholecystitis, stent migration, and occlusion 1.

Clinical Evidence

• Recent studies have shown that EUS-GBD boasts high technical and clinical success rates, ranging from 90% to 98.7% and 89% to 98.4%, respectively 1.
• The use of LAMS and FCSEMS has been compared in several studies, with LAMS showing promising results in terms of technical and clinical success rates, as well as lower adverse event rates 1.

From the Research

Management of Stent Migration in EUS-Guided Choledochoduodenostomy

To manage stent migration in EUS-guided choledochoduodenostomy, several factors should be considered:

• Stent type: The use of lumen-apposing metal stents (LAMS) or covered self-expandable metallic stents (SEMS) can affect the risk of stent migration 2, 3, 4.
• Stent placement technique: The technique used for stent placement, including the use of electrocautery-enhanced delivery systems, can impact the risk of stent migration 3, 5.
• Patient selection: Patient factors, such as the presence of malignant distal biliary obstruction, can influence the risk of stent migration 3, 4, 6, 5.

Strategies for Managing Stent Migration

Several strategies can be employed to manage stent migration:

• Endoscopic reintervention: In cases of stent migration, endoscopic reintervention may be necessary to reposition or replace the stent 3, 4, 6, 5.
• Use of dedicated stent designs: The use of dedicated LAMS or SEMS designs can help minimize the risk of stent migration 3, 4.
• Close follow-up: Regular follow-up is essential to monitor for signs of stent migration and to intervene promptly if necessary 2, 3, 4, 6, 5.

Adverse Events and Reintervention Rates

The adverse event rate and need for reintervention can vary depending on the stent type and placement technique used:

• Adverse event rates: The adverse event rate for EUS-guided choledochoduodenostomy using LAMS or SEMS can range from 7% to 36.8% 3, 4, 6, 5.
• Reintervention rates: The need for reintervention can range from 8.3% to 77.6%, depending on the stent type and patient population 3, 4, 6, 5.