Removal of Duckbill-type laser-cut anti-reflux metal stents: Clinical evaluation and in vitro study

Objectives: Duckbill-type metal stent (DMS) was the first laser-cut biliary metal stent with an anti-reflux valve. Removal of DMS is believed to be difficult and relevant reports are scarce. This study aims to investigate the feasibility of DMS removal. Methods: We retrospectively analyzed patients who underwent DMS removal between June 2019 and March 2022 to evaluate success rates and factors affecting outcomes. In addition, six different methods of DMS removal were reproduced in vitro, varying removal devices, angle of applied force, and grasped location. Extraction resistance, the distance of forceps stroke, and stent length after removal were compared. Results: Forty patients were enrolled, and DMS removal was successful in 31 cases (78%). No adverse events were observed. Tumor ingrowth was evident in 78% (7/9) of failed cases. Patients receiving biliary metal stents for the first time (naive cases), long indwelling time, longer stent, and stent tearing during removal were associated with unsuccessful stent removal. In the in vitro study, a larger force was required to remove the stent at an extraction angle of 120 degrees than at 0 degrees. Among cases in which force was applied at 120 degrees, the load tended to be lower when rat-tooth forceps were applied horizontally across the stent. Conclusions: Stent removal was possible in a majority of cases. Deployment of additional stents inside DMS may be preferable to forceful removal in the presence of factors associated with difficult stent removals, such as tumor ingrowth, naive cases, longer stents, long indwelling time, and stent tearing during removal.