In a clinically stable, fasting patient without contraindications to sedation, endoscopy, or contrast, how is a common bile duct stent removed endoscopically?

Endoscopic Removal of Common Bile Duct Stents

Common bile duct stents are removed endoscopically during ERCP, typically after 4-8 weeks once retrograde cholangiography confirms resolution of the underlying pathology (leak or stricture). 1

Standard Removal Technique

Timing and Pre-Removal Assessment

• Plastic stents should remain in place for approximately 4-8 weeks before removal, with timing guided by follow-up cholangiography demonstrating resolution of bile leaks or adequate stricture dilation 1
• For temporary biliary stents placed for common bile duct stones, definitive treatment (including stent removal) should occur within 4-6 weeks 2
• Retrograde cholangiography at the time of removal confirms healing and absence of residual pathology 1

Basic Removal Procedure

• The stent is grasped endoscopically using standard ERCP accessories (rat-tooth forceps, snares, or retrieval baskets) and withdrawn through the working channel 1
• Removable plastic stents are designed with features (flaps, strings, or flanges) that facilitate endoscopic extraction 1
• The procedure is performed under conscious sedation or general anesthesia, identical to standard ERCP 1

Management of Difficult Stent Removals

Proximally Migrated Stents

• Intrastent balloon inflation can successfully extract proximally migrated stents by inflating a balloon catheter within the stent lumen to create a grip for withdrawal 3
• This technique provides controlled traction without damaging the bile duct 3

Embedded or Tissue-Overgrown Stents

• The "stent-in-stent" technique involves placing a second fully covered metal stent inside the embedded stent, allowing both to be removed together after several weeks 4, 5
• This approach works by compressing hyperplastic tissue and creating a smooth extraction plane 4, 5
• For fully covered self-expanding metal stents (SEMS) that cannot be removed due to tissue hyperplasia or polymer damage, inserting a second fully covered SEMS within the existing stent for several weeks enables successful retrieval of both stents 4

Stents with Stone Encasement

• When stones develop around stents (typically after prolonged placement >2 years), the entire stent/stone complex must be removed en bloc while respecting the ductal axis to avoid perforation 6
• This complication underscores the critical importance of timely stent removal and definitive treatment rather than indefinite stenting 6

Critical Pitfalls to Avoid

• Never leave plastic stents in place beyond 3 months without replacement or removal, as occlusion becomes highly likely and stone formation around the stent can occur 6
• Biliary sphincterotomy should be performed during initial stent placement to facilitate subsequent removal and reduce complications 6
• Temporary biliary stenting is not a substitute for definitive treatment—stents placed for bile leaks or stones require follow-up intervention to address the underlying pathology 2, 7
• Uncovered metal stents should never be used for benign disease, as tissue ingrowth makes removal extremely difficult or impossible 5

Alternative Access When ERCP Fails

• Percutaneous transhepatic removal via existing PTBD tracts can be used when endoscopic access is not feasible, though this is reserved for cases where ERCP has failed 1
• Percutaneous approaches carry a 2.5% bleeding risk and are contraindicated with uncorrected coagulopathy 1