Obstruction of the biliary system can lead to a buildup of bile proximal to the level of obstruction [1] . Bile stasis proximal to the obstruction is prone to infection, causing ascending cholangitis, which can be fatal. Obstruction generally occurs in the setting of gallstones, but rare causes can include pancreatic mass, autoimmune disease, pancreas divisum, or ampullary adenomas [2] [3] . The addition of an expandable metallic stent (EMS) is the standard treatment. Following successful ERCP and sphincterotomy, putting a metallic stent prevents restenosis of the duct due to post-ERCP inflammation or extrinsic mass [4] . Metallic stents are broadly available in two types—covered and uncovered. Covered stents reduce tissue ingrowth but are susceptible to migration. They are readily removable. On the contrary, uncovered stents are preferred in extrinsic malignancies but can develop tissue ingrowth leading to obstruction [5] [6] .

We report a case of a serous cystadenoma impacting the common bile duct, leading to obstructive jaundice, warranting an ERCP-guided uncovered EMS placement. This was followed by a recurrence of the obstructive jaundice leading to the in-stent placement of a covered metal stent with a resolution of symptoms.

However, when the patient presented for a third time with obstructive jaundice with symptoms concerning an infection, supported by imaging for yet another blockage, a decision was made to replace the pre-existing stents with the covered EMS to avoid further blockage.

An 83-year-old man presented with fever, fatigue, and jaundice. He denied any history of vomiting, diarrhea, constipation, and loss of appetite. Family history is insignificant for congenital illness. He denies any travel to international countries. His presenting temperature was 101.3˚F, heart rate was 98, and blood pressure was 106/78 mm of Hg. On physical exam he had abdominal distension with right upper quadrant tenderness. Other systemic examination findings were unremarkable. No rebound tenderness, rigidity, or Murphy’s sign was appreciated. Examination of the other system was unremarkable. Lab work demonstrated elevated bilirubin levels in the blood with total bilirubin: 3.5 mg/dl, and elevated levels of transaminases, aspartate aminotransferase (AST): 394 U/L, alanine aminotransferase (ALT): 291 U/L, and alkaline phosphatase (ALP): 320 U/L. His blood cultures grew Klebsiella pneumoniae. Imaging demonstrated a pancreatic head mass of 3 × 5 cm, and a widening of the common bile duct up to 18 mm proximal to a preexisting stent with an obstruction within the stent and likely biliary sludge proximal to it.

Two months ago, he presented with features of obstructive jaundice (icterus, dark urine, pale stools). At that time, Computed Tomography (CT) showed a pancreatic mass, and the biopsy showed pancreatic serous cystadenoma. He had an uncovered metallic stent placed, but it was complicated by in-stent tissue growth presenting as cholangitis 3 weeks later. This prompted a repeat ERCP; ingrown tissue was dissected, and a covered EMS was placed inside the uncovered stent.

Finally, during this admission, an ERCP was decided upon for diagnostic and therapeutic purposes. At the duodenal papilla, an obstructed covered EMS inside an uncovered stent was seen. At first, the covered EMS stent was evacuated easily, and it led to the expulsion of pus, biliary sludge, and stones. The biliary tree was cleared utilizing balloon extraction. A cholangiogram was obtained showing narrowing at the level of the uncovered EMS. On further progressing the camera inside the bile duct, ample growth was noticed within the stent. A decision was made to remove the second stent. Initial tugging with forceps provided significant resistance. Dissection of the tissue growing into an uncovered metal stent was performed utilizing argon plasma (power: 15 W, pulsed mode, 1 L/min flow, effect 1) in a plane between the stent and the duct, breaking the ingrown tissue into the stent. The stent came off and was extracted using a rat-tooth alligator jaw grasp. Vacuuming was regularly done to diminish propelled gas in the duodenum. In almost 30 minutes, the uncovered EMS was removed.

By mechanical cleaning utilizing a balloon catheter, sludge inside the EMS was cleared off. A covered EMS was embedded to permit adequate drainage given the presenting cholangitis. Rectal indomethacin was given to decrease the risk of pancreatitis. Momentous change in the patient’s health was seen in the patient with slow normalization of liver function tests beginning with bilirubin, with discharge values indicating bilirubin of 0.9 mg/dL and AST/ALT/ALP of 84 U/L, 78 U/L, and 140 U/L, respectively. The patient was switched to oral antibiotics and discharged home the next day without complications.

The ERCP imaging are presented as follows ( Images 1-7 ):

Image 6. Ampulla of Vater post stent removal.

In our case, the expulsion of the biliary metallic stent was performed with argon plasma dissection in a satisfactory time without complication. Nowadays the argon plasma laser is broadly utilized in clinics around the world. Larger clinical studies are needed to establish APC settings, evaluate long-term outcomes, and develop guidelines for stent removal strategies. This case emphasizes the importance of technical skill and multidisciplinary judgment in endoscopic biliary interventions.