INTRODUCTION

A 75-year-old male underwent open cholecystectomy following an episode of cholecystitis (pathological anatomy with gallbladder adenocarcinoma).  During the surgery procedure, he presented a complete section of the common bile duct at the cystic duct level, and a bile leak in the subsegmental duct, both sutured. The patient's discharge persisted, and an ERCP was requested.

ENDOSCOPY

A large biliary leak was confirmed, and a  fully covered self expandible metal stent (SEMS) was placed. The patient subsequently presented with acute cholangitis, prompting ERCP for stent removal. Migration to the proximal common bile duct was observed, with no possibility of extraction with a Fogarty balloon, and a second stent was placed (SEMS in SEMS technique)

Two weeks later, a repeat ERCP was performed, with traction of the distal end using a polypectomy loop. The second stent was removed, but the migrated stent remained. Mobilization was achieved with a Fogarty balloon, but insufficient for removal

Finally, the decision was made to dilate the papillary area with a 13.5 controlled radial expansion (CRE) balloon and extraction of the stent over the balloon. There were not complications and confirming the absence of biliary leak.

CONCLUSION

Biliary stent placement is a technique used in patients with bile leaks. In our case, a covered metal stent was chosen due to the aforementioned history.

One of the complications of this technique is migration, with coaxial stent placement being a solution for its removal (the SEMS in SEMS technique)

The use of a CRE balloon for the removal of a migrated stent could be considered an effective and cost-effective alternative, even as a first option.