Endoscopic Removal of Biliary Stents

All endoscopic procedures were performed by experienced endoscopists or trainees under their direct supervision. Endoscopic stent removal was performed using either a duodenoscope or a single‐balloon enteroscope (JF‐260V, TJF‐260V, TJF‐Q290V, SIF‐H290S; Olympus Medical Systems, Tokyo, Japan) under conscious sedation with pethidine and midazolam. Before attempting stent removal or after attempting stent removal and experiencing resistance, biliary cannulation from the stent end or cannulation through the stent mesh was performed if possible. Balloon sweeping inside the stent was performed with stone extraction balloons under fluoroscopic guidance to check for contrast defects inside the stent suggesting tumor ingrowth. Rat‐tooth forceps, biopsy forceps, or a snare were used for stent removal at the discretion of the endoscopist. An attempt at stent removal was generally performed by grasping the stent with forceps or a snare, pushing the endoscope and twisting clockwise to move the stent slightly out of the bile duct, and regrasping further up on the stent near the ampulla to repeat the process. If unsuccessful, if strong resistance was felt, or if distal duodenal stenosis preclude pushing the endoscope, the stent was grasped and pulled together with the endoscope into the stomach. In either case, both the stent and the endoscope were carefully removed together from the patient's body under endoscopic and fluoroscopic guidance to avoid injury to the surrounding intestinal tract.