From the Guidelines
Management of stent migration after EUS-choledochoduodenostomy should prioritize prompt intervention with endoscopic retrieval for proximally migrated stents and conservative management with monitoring for distally migrated stents, unless complications arise. The approach to managing stent migration involves several key steps, including confirmation of migration through imaging such as abdominal X-ray, CT scan, or repeat EUS 1.
Assessment and Initial Management
For proximal migration into the bile duct, retrieval can be attempted using endoscopic methods with rat-tooth forceps, snares, or balloon catheters during ERCP or repeat EUS. This approach is technically demanding and should be performed by skilled endoscopists, as highlighted in the context of EUS-BD placement having improved outcomes with experience 1.
Conservative Management
For distally migrated stents that have entered the intestinal tract, conservative management with monitoring is appropriate if the patient is asymptomatic, as most stents will pass naturally within 1-2 weeks. However, close monitoring is crucial to promptly identify any signs of complications.
Prevention of Future Migration
To prevent future migration, considering using stents with anti-migration features such as double-pigtail designs, lumen-apposing metal stents (LAMS), or partially covered self-expandable metal stents with wider flanges is recommended. Proper stent placement technique is also crucial, ensuring at least 1-2 cm of the stent remains within the bile duct and that the distal end is adequately positioned in the duodenum.
Follow-Up
Regular follow-up imaging at 1-3 month intervals is recommended to monitor stent position until removal or exchange is planned, typically at 3-6 months post-procedure. This proactive approach helps in early detection of any potential issues, including stent migration, and allows for timely intervention to prevent serious complications.
From the Research
Management of Stent Migration after EUS-Choledochoduodenostomy
To manage stent migration after EUS-choledochoduodenostomy, several strategies can be employed:
- Re-intervention: In cases of stent migration, re-intervention may be necessary to replace or reposition the stent 2.
- Stent design: The use of fully covered or partially covered self-expandable metal stents (SEMS) may help reduce the risk of stent migration 3, 4.
- Technique: Following the recommended procedure technique and using a cautery-enhanced delivery system may also help minimize the risk of stent migration 5, 6.
- Patient selection: Careful patient selection and evaluation of the common bile duct diameter may help identify patients at higher risk of stent migration 5.
Risk Factors for Stent Migration
Several risk factors for stent migration have been identified, including:
- Small diameter of the common bile duct 5
- Not following the recommended procedure technique 5
- Type of stent used: Fully covered SEMS may have a higher risk of migration compared to partially covered SEMS 4, 2
Outcomes of EUS-Choledochoduodenostomy
The outcomes of EUS-choledochoduodenostomy using different types of stents have been evaluated in several studies: