title: Endoscopic removal of malfunctioning biliary self-expandable metallic stents.
abstract: BACKGROUND
  Endoscopic removal of malfunctioning self-expandable metallic biliary stents (SEMS) is difficult and not well described. The aim of this study is to review the indications, the techniques, and the results of SEMS removal in a cohort of patients with malfunctioning stents.
  
  
  METHODS
  All patients who underwent an attempt at endoscopic removal of biliary SEMS over a 5-year period were retrospectively identified. The main indications for SEMS removal were the following: distal migration of the stent or impaction to the duodenum, impaction into the bile-duct wall, tissue ingrowth, and inappropriate length of the stent causing occlusion of intrahepatic ducts. SEMS were removed by using foreign-body forceps or polypectomy snares.
  
  
  RESULTS
  Endoscopic removal of 39 SEMS (13 uncovered and 26 covered) was attempted in 29 patients (17 men; mean age, 66 years). SEMS extraction was attempted after a mean of 7.5 months (8.75 months standard deviation) post-SEMS insertion. Removal was successful in 20 patients (68.9%) and in 29 SEMS (74.3%). Covered SEMS were effectively removed more frequently than uncovered ones: 24 of 26 (92.3%) and 5 of 13 (38.4%), respectively (p < 0.05). No major complications were recorded. Multivariate analysis showed that the time interval between insertion and removal, SEMS length, stent-mesh design (zigzag vs. interlaced), and indication for removal were not predictive of success at stent removal.
  
  
  CONCLUSIONS
  Endoscopic removal of biliary SEMS is feasible and safe in more than 70% of cases. Because only 38% of uncovered SEMS were removable, the presence of a stent covering is the only factor predictive of successful stent extraction. The presence of diffuse and severe ingrowth was the main feature limiting SEMS removal.
authors.affiliation: Digestive Endoscopy Unit, Catholic University, Rome, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Familiari
authors.forename: Milutin
authors.initials: M
authors.lastname: Bulajic
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Mutignani
authors.forename: Linda S
authors.initials: LS
authors.lastname: Lee
authors.forename: Gianluca
authors.initials: G
authors.lastname: Spera
authors.forename: Cristiano
authors.initials: C
authors.lastname: Spada
authors.forename: Andrea
authors.initials: A
authors.lastname: Tringali
authors.forename: Guido
authors.initials: G
authors.lastname: Costamagna
mesh_terms: D000368:Aged; D001659:Biliary Tract; D002779:Cholestasis / Q000209:etiology; D020878:Device Removal; D016145:Endoscopy, Digestive System; D004868:Equipment Failure; D005260:Female; D005548:Foreign-Body Migration / Q000150:complications / Q000628:therapy; D006801:Humans; D008297:Male; D015607:Stents / Q000009:adverse effects*