From the Guidelines
To manage stent migration in EUS-guided choledochoduodenostomy, the use of fully covered self-expanding metal stents (SEMS) with antimigratory properties is recommended, as they have shown a technical and clinical success rate of 100% in a recent study 1. When managing stent migration, it is essential to first confirm the migration with imaging (CT or fluoroscopy) to locate the displaced stent.
Key Considerations
- For minor distal migration, endoscopic repositioning using rat-tooth forceps, snares, or balloon catheters can be attempted.
- For complete inward migration, a rescue stent placement may be necessary to maintain biliary drainage while planning retrieval.
- The initial stent placement should prioritize fully or partially covered SEMS with diameters of 8-10mm and lengths of 6-8cm, ensuring at least 1-2cm protrusion into the duodenum with anchoring features like flared ends or anti-migration flanges.
- Double-pigtail plastic stents can be placed through SEMS to prevent migration, although straight stents may have more pushability than pigtail stents, they have a higher migration rate 1.
Prevention Strategies
- To minimize migration risk during the initial procedure, use a cautery-enhanced lumen-apposing metal stent (LAMS) of 10-15mm diameter.
- Perform tract dilation conservatively (4-6mm).
- Consider fistula maturation for 2-4 weeks before stent exchange.
Complication Management
- If biliary leakage occurs due to migration, temporary nasobiliary drainage or repeat stenting may be necessary, along with antibiotics for cholangitis prevention, as recommended by consensus guidelines 1.
From the Research
Management of Stent Migration in EUS-Guided Choledochoduodenostomy
- Stent migration is a potential complication of EUS-guided choledochoduodenostomy, with a reported incidence of 9.3% in one study 2.
- The use of lumen-apposing metal stents (LAMS) has been shown to reduce the risk of stent migration, with one study reporting no cases of migration in 19 patients 3.
- However, another study reported a case of stent migration in one patient out of 54 (1.9%) who underwent EUS-guided choledochoduodenostomy using a LAMS 2.
- The use of an electrocautery-enhanced LAMS may also help to reduce the risk of stent migration, with one study reporting no cases of migration in 120 patients 4.
- In cases where stent migration does occur, re-intervention may be necessary, with one study reporting that 8.3% of patients required biliary re-intervention after initial technical success 4.
Prevention of Stent Migration
- The use of an axis-orienting stent through the lumen of the LAMS may help to reduce the need for biliary re-interventions, including those due to stent migration 5.
- One study reported that the insertion of an axis-orienting stent through the lumen of the LAMS reduced the need for biliary re-interventions from 50% to 5% 5.
Treatment of Stent Migration
- Re-intervention may be necessary in cases where stent migration occurs, with options including the placement of a new stent or the use of other endoscopic techniques to restore biliary drainage 2, 4.
- The choice of treatment will depend on the individual patient's circumstances and the underlying cause of the stent migration.